BOUNCE OUT THE STIGMA 2017 Saturday Afternoon Basketball Clinic

Special Needs Basketball Clinic 5 Weeks on Saturday Afternoons, Starts January 7, 2017 |  Glen Rock, NJ

Basketball Camp Registration Bounce Out the Stigma

Glen Rock Clinic Special Needs Basketball

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Cost of this Clinic is $50.00 – Which Covers 5 Weeks and Each Child Gets a Basketball and Certificate of Accomplishment

 In Conjunction With and Our Underwriting Sponsor
Julia Anne Kirsch FoundationLearn More About Julia Anne Kirsch Foundation 

 SPACE IS LIMITED – This Clinic Will Fill Up Fast, Please Register Now, Using This Form

REGISTRATION FORM

SELECT 2017 CAMP SESSION & LOCATION*:

CAMPER INFO:

Parent or Guardian's Name * :

Your Relationship to Camper *:

Campers Name ( first, last name only if different from yours } * :

Campers Nick Name:

Campers Age * on January 1, 2017 :

Campers Grade as of January, 2017 * :

T-Shirt Size * :

Returning Camper*: YESNO

YOUR CONTACT INFO:

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.

Add Me To Your Newsletter: YesNo

*Please Tell Us How You Heard About Us

* REQUIRED

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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