Poynette Basketball Club - (Poynette, WI) - powered by LeagueLineup.com

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PLAYER INFORMATION

* First Name:

* Last Name:

* Street Address:

PO Box:

* City:

* State:

* Zip Code:

* Home Phone:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

First Name:

Last Name:

EMail:

* Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

WAIVER INFORMATION

*** Insert your waiver information here ***

I/we agree with the above *

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Signature:

Date:

* indicates required fields