NC Lakers Signup Form

Name*
First Last
Gender*
- Male
- Female
Age*
School*
Grade Year 2015-2016*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mothers Name
First Last
Fathers Name
First Last
Parents Contact Phone*
Emergency Contact*
First Last
Relationship*
Phone*
Specify any of your childs health problems*
Is Your Child on Any Medication?*
- No
- Yes
If Yes, please specify
Tryout fee: $10 of which will help pay for facility

Contact Information

Email: mikegriffin@nclakersbasketball.com
Email
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