Elite Basketball Shootouts-2023

College Exposure Application-

(please print clearly)

First Name _______________________Last Name _____________________________ Gender ____

Address_________________________________ City ________________________ State ________

Zip code ___________ Telephone ____ _____ _______

Email address _________________________________________ Height _______ Weight ______

Graduation year (circle one) ___2023 __ 2024 ___2025 ___2026___2027

High School _______________________________ city________________________ state ______

Parent Consent and Medical Information (Players cannot participate unless they have medical insurance).-

Players cannot participate unless this section has been completed and signed by the parent or guardian.
 I understand that the Showcase and the host venue does not carry medical or accident insurance for the
 participants, and I hereby certify that my child is covered by personal insurance or is included in a policy
 which I have in place. I authorize routine medical care for my child by the Shootout trainer. I further
 authorize any treatment considered routine to be referred to a local physician or to an emergency room
 at my expense. I further authorize and provide my consent and permission for my child to participate in
 this event.
Insurance Company ____________________ Policy _____________ Group # ________

Name of Policy Holder _____________________________ Home Phone __________

Signature of parent/guardian _________________________ Cell phone _____________

Payment choices. Check one: ____ check,  ____ money order, ____ credit card (Go to our webpage-
www.pahoops.org  and click on the BUY NOW BUTTON to make your credit card payment).
If you pay by check or money order, print this application and send it.    Make your check or money order
payable to Bill Gaffey.

______ Friday   June 9-    -Early registration $138.00 before 5/23/23 or $148 later.

______ Sunday August 13-Early registration $138.00 before 7/28//23 or $148 later.

______Sunday October29-Early registration $138.00 before 10/10/23 or $148 later.

Mail to Bill Gaffey,  417  Bolton Drive,  Harrisburg  PA   17112

or scan and email to wgaffey@pa.net

Our website:   www.pahoops.org    Follow us on Twitter at @Pa_Big60