06/07/08 College Prep Boys Registration Player InfoPlayer Name First Middle Last Gender Male Female Age Date of Birth MM slash DD slash YYYY Years played for BFLA: HiddenTeam by Age Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhonePosition Athlete Shirt Size Youth Small Youth Medium Youth Large X-Small Small Medium Large X-Large Parental/Guardian InformationMother/Guardian Name First Last Email Cell PhoneWork PhoneHome PhoneFather/Guardian Name First Last Email Cell PhoneWork PhoneHome PhoneList Name of Person(s) Permitted to Collect Athlete Other Than Parents (If Any)Name First Last Relationship to Athlete Email Cell PhoneOther PhoneList Name of Person(s) Permitted to Collect Athlete Other Than Parents (If Any)Name First Last Relationship to Athlete Email Cell PhoneOther PhoneSignatures, Disclaimers and Terms of AgreementMedical Emergency(Required)I understand that I will be notified in the case of a medical emergency involving my child. In the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I agreeMedical Expenses(Required)I understand that the Bascome Enterprise and/or its Staff will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I agreePhoto Release(Required)I understand the photos will be used to keep a journal of activities, to share during power point presentations, for promotional purposes including flyers, brochures, newspapers and/or reports to our donor Bascome Enterprise. I agreeTerms(Required)The Bascome Enterprise and its co-organizers are not responsible for lost or damaged personal property. All scheduled events are subject to change. I understand that no fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. The child’s photos and quotes may be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, and/or Physician). I agreePayment Terms(Required)Bascome Enterprise (BFLA) is a 12-month program broken down into six payments. June 1st, July 1st, Aug 1st, Sept 1st, Nov 1st and Feb 1st. Payments All payments MUST be received prior to the players starting. Players not paid will not be able to play or train until payments have been made. Registration Deadlines All payments MUST be received prior to the start of training. I agreeSignatureBy typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. First Last Date MM slash DD slash YYYY Payment InformationOption(Required) Initial Registration Only ($500) Full Year Registration ($1975) *Initial registration includes registration fee ($250), jerseys and uniforms ($120), and 2 months of coaching fees ($130). *Full Year Registration includes registration fees, full year coaching fees, 4 fall tournaments, 2 indoor sessions, 1 indoor tournament, spring league fees, 2 spring tournaments, uniforms, coaching education fees, equipment, Baltimore Blast partnership fee (includes a ticket to a Baltimore Blast game), and facility costs.Total Credit Card Cardholder Name Card Details PhoneThis field is for validation purposes and should be left unchanged.
