Clinic Registration Form

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You must register either online with this form or by calling us at 855.997.3900

Special Needs Basketball Clinic

This clinic is uniquely designed for children with SPECIAL NEEDS, (Autism, ADD, ADHD, Epilepsy, Neurological Disorders, Downs Syndrome). There is a 4:1 Camper to Coach Ratio so all children will receive a great deal of personal attention. Every child will receive a special participation medal.  Please do not register if there is a chance you may not attend. We require a parent or guardian be present during this event.   Clinic will be run by Mighty Mike Simmel

 Please answer all questions,
thank you.

Registration Information for the Clinic:

Parent or Guardian's Name * :

Your Relationship to Child *:

Child's Name* ( first, last name only if different from yours } * :

Child's Nick Name:

Child's Age * on Sept. 1, 2015 :

Child's Grade as of Sept. 2015 * :


Your Email Address *:

Tel. # We Can Reach You* : (format 201-555-1212)

Home Address* :

City* :

Your State* : Zip * :

Please Feel Free to Share Any Additional Information About Your Child, that you feel would be helpful in allowing he/she to have a fantastic experience.

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*Please Tell Us How You Heard About Us


If you do not receive a call or forms in the mail in 2 weeks, Please call us at 855.997.3900.

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If you cannot make the clinic be sure to sign up for the Bounce Out the Stigma Newsletter to learn about other events and our 2016 Summer camp schedule.


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