4-HIM Basketball Registration 2015 Registration Fee: $25 Program Conducted by Lewis Lane Baptist Church Participant Contact Info: Last Name: ________________________ First Name: _____________________ MI: _____ Address: ____________________________________________________ City: _________________________ State: ______ Zip: ____________ Church (if you regularly attend church, which one?) ___________________________ Grade: ___________ Date of Birth: _____/______/_______ How many years has your child played organized basketball? _________________ Does child have any medical conditions or allergies we need to know about? _________________________________________________________________________ Parent/Guardian Information: Mother’s Last Name: ______________________ First Name: _____________________ Address (if different than above):____________________________________________ Cell Phone: _______________ Texting (Y/N): ______ E-mail: __________________________ Home Phone: _______________ Are you willing to Coach or Referee: _________ Father’s Last Name: ______________________ First Name: _____________________ Address (if different than above): ____________________________________________ Cell Phone: _______________ Texting (Y/N): ______ E-mail: __________________________ For League Use: Home Phone: ________________ Are you willing to Coach or Referee: __________ Registration Fee Paid (Y/N?) _______ Check Number ________ or Cash ________ Shirt Size: ___________ Height: ____________ Lane Shooting_______ Right Hand Dribble ______ Right Side Shot ______ Left Hand Dribble ______ Left Side Shot_______ (OVER)
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