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Print Form Moncton Kiwanis Minor Basketball Association PRE-REGISTRATION FORM FOR SALISBURY LEGUEA Return Address: 53 Douglas Street, Salisbury New Brunswick E4J 2B4 Office Use FIRST NAME LAST NAME PARENT NAME ADDRESS TOWN / VILLAGE POSTAL CODE HOME PHONE DATE OF BIRTH GENDER MEDICARE NUMBER AGE LEVEL Other MKMBA Family Members PUPPY 2000-2001 1 JR. MINI 1998-1999 2 MINI 1996-1997 3 BANTAM 1994-1995 MIDGET 1990-1993 CAN NOT PRACTICE We can only TRY to accommodate MONDAY WEDNESDAY TUESDAY THURSDAY FRIDAY I am interested in FEES Coaching Assisting Coach Number of Players 1st Player 2nd Player Each add. player PUPPY User Fee PER Player $80.00 $70.00 $10.00 $55.00 $10.00 AMOUNT PAID CASH CHEQUE CHQ. # Do you wish to be contacted for Provincial YES NO Try-Outs NO REFUNDS AFTER SEPTEMBER 30TH 2007 My Child's Picture CAN be on the village web site or MKMBA web site YES WAIVER I hereby waive and release the Moncton Kiwanis Minor Basketball Association, it's agents, coaches and officials from any claim or action for any injury received by my child in coming, going,or during association activities. INSURANCE Parents and Coaches are advised that any injury incurred during MKMBA activities should be reported to the MKMBA office IMMEDIATLY. Signature of Parent / Guardian Date