Skills Development Program 2010 - 2011 Registration:

Session I: Saturdays: October 16, 2010 - December 18, 2010 & Sundays: October 17, 2010 - December 19, 2010

Session II: Saturdays: January 08, 2011 - March 12, 2011 & Sundays: January 09, 2011 - March 13, 2011

Locations:
Jeunes Sans Frontieres School, 7585 Financial Drive, Brampton
St Joseph Secondary School, 5555 Creditview Road, Mississauga


Registration Form: Please complete the form below and submit.

Program:
Mini (5 - 7 yrs): Saturdays 9am - 10:30am - $260.
Jeunes Sans Frontieres School
Novice (8 - 9 yrs): Saturdays 10am - 12noon - $275.
Jeunes Sans Frontieres School
Atom (10 - 11 yrs): Mondays 6pm - 8pm - $295.
Jeunes Sans Frontieres School
Bantam(12 - 13 yrs): Saturdays 10am - 12noon - $295.
Jeunes Sans Frontieres School
Midget(14 - 15 yrs): Saturdays 2pm - 4pm - $295
St Joseph Secondary School

All participants will receive a uniform and trophy.

Information type

Family Guardian

Parent/Guardian 1:  
Relationship: Mother Father Other
Salutation: Mr. Mrs. Ms. Other
Last Name:
First Name:
Home Telephone:
Business Telephone:
Cellular Telephone:
Fax Number
Email:
Parent/Guardian 2:  
Relationship: Mother Father Other
Salutation: Mr. Mrs. Ms. Other
Last Name:
First Name:
Home Telephone:
Business Telephone:
Cellular Telephone:
Fax Number:
Email:
Secondary Contact (if above cannot be reached):  
Name:
Telephone Number:
Relationship to Participant:
Mailing Address of Family:  
Street:
City:
Postal Code:
Billing Address:
(If it is the same as mailing address, please enter the word "same" in every field.)
Street:
City:
Postal Code:
Phone Number:
Athlete Information:  
Surname:
First Name:
Commonly Used Name:
Sex: Male Female
Birthday:
Health Card Number:
Previous Basketball Experience (if any):
Uniform Size:

Youth: S M L XL

Adult: S M L XL XXL

Medical Information:  
Height (inches):
Weight (lbs):
Allergies:
Requires an Epi-Pen: Yes No
Immunizations Up to Date: Yes No
Is the athlete taking any prescription medication: Yes No
Please list any other medical concerns:
Doctor's Name:
Doctor's Telephone:
Please read the medical waiver.  
By checking this box, I am stating that I have read and agreed to the above medical waiver: Date:

Conditions of Registration:

  
Please read the terms and conditions.  
By checking this box, I am stating that I have read and agreed to the terms and conditions: Date:

Media Release:
I wish to support the Mississauga Wolverines, a non-profit organization. I allow photographs to be taken of my son/daughter playing basketball in order to support their multi-media promotional requirements for photographs, brochures, website and other marketing materials.

By checking this box, I am stating that I have read and agreed to the above media release. Do not check the box, if you do not wish to provide media release.
Date:

*THIS APPLICATION MUST BE COMPLETED IN FULL BEFORE BEING CONSIDERED.

*PLEASE SEND PAYMENT TO: P.O. Box 906, 145 Queen St. South, Mississauga, ON., L5M 2L0

*APPLICATION WILL NOT BE CONSIDERED UNTIL APPROPRIATE FEES ARE RECEIVED.