Registration Form

Please print and complete the form below and mail this with amount indicated to: B.A. Sports Show-Me Showcase, PO Box 563, Dexter, MO 63841.

YOU MAY SELECT ANY OF THESE FORMS OF PAYMENT:
CHECK, MONEY ORDER, VISA, MASTERCARD, AMERICAN EXPRESS OR DISCOVER.

____ Register by Sept. 4, 2004 - $25/person (MUST PRE-REGISTER)
____ Register by Sept.11, 2004 - $40/person (MUST PRE-REGISTER)

THE ENTRY FEE IS NON-REFUNDABLE

$______ TOTAL AMOUNT ENCLOSED

METHOD OF PAYMENT (CIRCLE):
CHECK  MONEY ORDER  MASTERCARD  VISA  AMEX  DISCOVER

CREDIT CARD NUMBER ____________________________ EXP.DATE _______________

Please print carefully. The information will be used by scouts.

LAST NAME _______________ FIRST NAME _______________

ADDRESS _________________________ APT __________

CITY __________________ STATE ______ ZIP _____________

AREA CODE __________ PHONE NUMBER __________

GRADUATION YEAR __________   HIGH SCHOOL OR JUCO OR NEITHER

E-MAIL ADDRESS ________________ BIRTHDATE __________

CURRENT SCHOOL ____________________ HT. ____ WT. ____

SCHOOL ADDRESS _________________________

CITY ____________________ STATE _______ ZIP __________

POSITION ____ PPG ____ RPG ____ APG ____ STEALS ____

HEALTH INSURANCE PROVIDER __________

HEALTH AND BEHAVIOR GUIDELINES
I, the undersigned, submit my child is physically fit to participate in strenuous athletic activity and waive B.A. Promotions, Inc. of any and all responsibility for injury or illness. I hereby authorize the staff of B.A. Promotions, Inc. to act for me according to their best judgement in any emergency requiring medical attention. I understand that I am solely responsible for the payment of such medical expenses and must provide B.A. Promotions, Inc. with proof of medical and accident insurance. I also understand that my entry fee is non-refundable and non-transferable. I understand that any participant who does not abide by facility rules or regulations is subject to dismissal without refund or recourse.

Signature of Parent or Guardian

________________________________________ Date __________