Clinic Reg Form

BROADMEADOWS BASKETBALL ASSOC. Dimboola Rd, Broadmeadows Postal: PO Box 1407, Tullamarine VIC 3043 Ph: 03 9309 5655 / F: 9309 7169 E: [email protected]

HOLIDAY CLINIC: Summer Basketball Camp REGISTRATION FORM: # of Children: _____________ Cost (above x $40): ___________ Child/ren Name/s & Age/s: ______________________________________________ Parent/Contact Name: __________________________________________________ Contact Phone: ________________________ Email: _________________________ METHOD OF PAYMENT (please tick & complete details): CASH – please drop to Broadmeadows Stadium BEFORE Wed 16th Dec 2009*.

CHEQUE – please make payable to Broadmeadows Basketball & post (details above).

CREDIT CARD - please phone 9309 5655 or post.* Card Type (Pls Circle): VISA

/

MASTERCARD

Name on Card: ____________________________________________________ Card Number: _____________________________________________________ Expiry: _________________________

Please Note: Canteen will be open for snacks, drinks and lunch orders (hot food) on both days. Please ensure child/ren wear rubber sole/non-marking shoes and bring a drink bottle. *The basketball stadium will close for the Christmas period from Thursday 17th Dec 2009 and re-open on Monday 17th January 2010.

www.broadmeadows.basketball.net.au