2010-2011
Athlete’s Name_______________________________ Nickname ________________
Grade____________________ Height ___________________
Date of Birth ______________ Age as of Sept. 1st __________
Home Phone ____________________ Player’s Cell Phone________________________
Parents’ Names _________________________________________________
Parents’ Cell Phone(s) _________________ (dad) ____________________ (mom)
Player’s Email_______________________@____________________________
Parents’ Email_______________________@_____________________________
Street Address___________________________________________________
City, State Zip __________________________________________________________
Parents, please sign below.
2010-2011 Basketball Season________________________________ □ pd __________
date
Registration dates/fees are as follows:
Basketball Season $200* Register by Sept. 17th Pay by Oct. 1st (Add $25 late fee
after October 1st)
*Additionally, each family will be required to sell one $100 ad to be included in the
game programs. (More ads may be sold to offset costs. Sponsor forms and payments due by Oct. 1st)
Mail registration and payment to:
Shelby Glenn
1305 N 159th Street
Omaha, NE 68118
Make checks payable to the