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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