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Registration Form

 Basketball Volleyball
 Bquick Speed/Agility Camps Others
 Spring Summer Fall     Year:
Students Name:

Age:

DOB:

Gender:

School:

Grade:

Training:

Teams:

Any Injuries or conditions:

Parents/Guardians Names:
Address:
City:
Zip:
Email(1):
Email(2):
Phone(H):
Cell:
Emergency Phone:
Fathers Place of Employment:
Title and / or Position:
Mother’s Place of Employment:
Title and / or Position:
Waiver of Liability:
 I agree that I will not hold Northshore Sportsplex, Northshore AAU Titans, or Charles Tracey responsible for any injuries sustained or illness contracted while a participant at or on the premises of NSSP, LLC
Please make your check payable to "Northshore Sportsplex" and mail to us at
563 Greenluster Dr., Covington, LA 70433.