Fall  2004
Basketball Shootouts
In the past players have attended from West Virginia, Virginia, Delaware, D. C., Maryland, Ohio, New York, North Carolina, Michigan, New Jersey, Pennsylvania, Vermont and Canada.

Oct 10, 2004
Cumberland Valley H. S.
Mechanicsburg, PA  directions
Separate sessions for boys and girls at this site
Oct 3, 2004
Alvernia College, Reading, PA  directions
Separate sessions for boys and girls at this site

Name

Address

City

Graduating year

High School

City

School phone

State

Zip code

Home phone

Height

Birth date

State

Zip code

 Academic Information:  SAT-M _____  SAT-V ____ PSAT-M ____ PSAT-V ____

Coaches Name _____________________________ Coaches Phone ______________

Address _________________________ City _______________ State _____ Zip _____

 Parent Consent and Medical Information
(Players cannot participate unless they have medical insurance).
(Players cannot participate unless this section has been completed and signed by the parent or guardian). I understand that the Shootout and the host school do not carry medical or accident insurance for the participants, and I here by certify that my child is covered by personal insurance or is included in a policy which I have in place. I authorize routine medical care for my child by the Shootout trainer. I further authorize any treatment considered routine to be referred to a local physician or to an emergency room at my expense. I further authorize and provide my consent and permission for my child to participate in this event.

Insurance Company ____________________ Policy _____________ Group # ________

Name of Policy Holder _____________________________ Home Phone __________

Signature of parent/guardian _________________________ Cell phone _____________