Fremd Feeder Registration 2009-10

Players Name:________________________________________________________

Parents name:________________________________________________________

Address________________________________State:__________Zip:___________

Home #______________________Cell#___________________Wk.#____________

Email:_______________________________________________________________

DOB:_________________________Age:______________Grade:________________

School:______________________________________________________________

Emergency Contact: Name___________________________Phone:________________

Any health concerns:_____________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Insurance Co:__________________________________________________________

Policy #:______________________________________________________________

Waiver Signature:_______________________________________________________
(must sign to participate)

Costs
Player Fee (1st payment)	$425. due by 11/1/2009
(2nd payment)	$265. due by 1/8/2010
TOTAL DUE
Balance due by 1/8/2010

Print and complete this form.  Make check payable to: 
Fremd Feeder Boys Basketball
305 College Crossing
Rolling Meadows, IL 60008