REGISTRATION FORM

Fill in the required information in this form and click the SUBMIT button.
PRINT this page and MAIL a copy along with HALF the registration fee to:
ED PALUBINSKAS
12625 PECOS AVE.
GREENWELL SPRINGS, LA. 70739
PH: 1-800-784-6674 PH: (225) 262-0607 FAX (225) 262-0600 CELL (225) 324-6022

CLINIC DATE

NAME

FATHER’S NAME

ADDRESS

CITY

STATE

ZIP

PHONE (DAY)

CELL PHONE

EMAIL

AGE

HEIGHT

GRADE

MALE

FEMALE

SCHOOL

COACH’S NAME

INSURANCE

IT IS THE RESPONSIBILITY OF EACH CAMPER’S PARENT/GUARDIAN TO PROVIDE MEDICAL COVERAGE NECESSARY IN THE EVENT OF AN ACCIDENT THAT REQUIRES MEDICAL ATTENTION.

INSURANCE  CO.

POLICY NUMBER

I HEREBY AUTHORIZE A REPRESENTIVE OF THE PALUBINSKAS BASKETBALL ACADEMY/CAMP TO SEEK MEDICAL ATTENTION SHOULD THE NEED ARISE.

PARENT/GUARDIAN

BE ADVISED THAT THE PBA WILL STILL PROVIDE COVERAGE OF EACH PARTICIPANT FROM OUR SIDE TO ENSURE THAT EACH PERSON HAS COVERAGE IN THE EVENT OF AN ACCIDENT. THE SAFETY OF YOUR CHILD IS OF UTMOST IMPORTANCE TO US AT THESE CLINICS.