Ohio Express Basketball Membership Application for 2012

player Information

Name:

Date of Birth:

School:

Grade (2011-2012):

Playing Experience

Height:

Weight:

Uniform # (pick 3 #s):

Medical Problems:

contact Information

Current Address:

City, ST, Zip code:

Home Phone:

E-mail:

Fathers Name:

Daytime Phone:

Cell Phone:

Mothers Name:

Daytime Phone:

Cell Phone:

Emergency Contact

Name of a relative not residing with you:

Address:

Phone:

Relationship:

Other activities

List all sports, clubs, and other organizations the player is involved in:

 

signatures

Signature of parent:

Date: