Address:

Day Phone:

Evening Phone:

E-Mail:

League:
Boys
Girls

Grade:
4th/5th Grade (Girls and Boys)
6th Grade (Girls)
7th Grade (Girls)
8th Grade (Girls)
9th Grade (Girls and Boys)
10th Grade (Boys)

Name Of Parent/Guardian:

Parent/Guardian Phone:

Parent/Guardian Email:

Player For 2021 Season: $150
Uniform Fee: $65

By hitting "Send" I acknowledge my son/daughter is physically fit to participate in strenuous athletic activity and I waive Rome Select Basketball of any and all responsibility resulting in Injury or Illness. I hereby authorize the directors / coaches of Rome Select basketball to act for me according to their best judgment in any emergency requiring medical attention. I understand that I am solely responsible for the payment of any such medical expenses and must provide this organization with proof of medical and accident insurance before playing in any tournaments.