May 21, 2017-Elite College Exposure Application-The Big 60
21 at Lancaster Bible College
this is for individual players,
First Name ____________________________Last
Name ________________________________ Gender _______
City _______________________________ State ________ Zip code ___________
Print email address _______________________ Home phone ____________________ Birth date ____________
Height _______ Weight
Graduation year (circle one)
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 on
___________ For May 21- $128.00 Boys Shootout, early registration- at Lancaster Bible College- late registration May 6 to day of the event $140.00.
___________ For May 21 $128.00 Girls Shootout, early registration- at Lancaster Bible College-late registration May 6 to day of the event $140.00.
Send your check or money order with your application (Make your check payable
to: Bill Gaffey,)
and send your completed application.
-- or pay by credit card on Pay Pal
To pay by credit card on Pay Pal, click on the button, "Buy Now" (Make your payments payable to: Bill Gaffey, you don't need a Pay Pal account to make your payment) Denote who the payment is for!!
No refunds during last week of the event and mail to: Bill Gaffey 417 Bolton Drive, Harrisburg, PA 17112-- call 717-545-0872------email firstname.lastname@example.org