Filipino - American Youth Basketball Association

8591 Tyrolean Way, Springfield, VA 22153

Tel. 202.415.0880

Email : fyba2007@verizon.net

Website : www.fybaonline.com

PERMISSION AND RELEASE FORM

Basketball League Basketball Clinic
Name
Last First Middle
Birthdate
YearMonthDate
Age
Gender
Height
Weight
Street Address
City
State
Zip
Email
Phone Number
Parent / Guardian Name
Health Insurance

I hereby give permision for
To participate in the above activity and agree that he/she will abide by all the rules and regulations of the facility/area and /or the Filipino-American Youth Basketball Association, it’s designated officers and agents.

In case of accident or illness, please contact at (phone)

My family physician is
In the event of an accident or injury, I hereby waive liability, as parents and guardian of the above child, for the Fil-Am Youth Basketball Association and their officers, and will hold harmless. I understand that there is no medical insurance being provided by the Filipino-American Youth Basketball Association.

Venue: Hayfield Secondary School     Time: Sundays 1-7 pm

FEES: (Includes 2 sessions of clinic, minimum of 6 games – Pls. check one)

MOSQUITO $50.00 Boys & Girls - Ages 4 to 6
BEES $60.00 Boys & Girls - Ages 7 to 9
TYKES $75.00 Boys & Girls - 10&under (Clinic not included)
PEEWEE $75.00 Boys Ages 11 to 12 - (Clinic not included)
BANTAM $80.00 Boys 13 to 14 - (Clinic not included)
JUNIOR $75.00 Boys 15 to 17 - (Clinic not included)
GIRLS $75.00 Girls 12 to 16 - (Clinic not included)
OPEN $700.00 No age limit
SENIORS $700.00 (32 and up) - Players 32 years of age on the year league are eligible to play.
MASTERS $700.00 (40 and up) - Players turning 40 years of age on the year of the league are eligible to play. 38 years old are no longer allowed.

 I agree for the terms and condition. As a signature, I'll mark this checkbox as I agree.

Please make your check payable to: FYBA INC.

Send the form along with the check to the address below on or before February 15, 2012.

FYBA INC.

8591 Tyrolean Way

Springfield, VA 22153

  
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