| Player Information | |
|---|---|
| Player Name | Kason Blum |
| Player's Date of Birth | 04/07/2019 |
| Do you have another player to register? | No |
| Do you have a player/coach that you would like to be on the same team with? | No |
| Please enter the players/coaches names | Team 5 - Buresh |
| Player Registration | Player Registration, Qty: 1, Price: $250.00 |
| Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement | By submitting this I accept the terms of the aforementioned Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement. |
| Parent-Guardian Information | |
| Parent / Guardian Name | Tom Blum |
| Parent / Guardian Email | Email hidden; Javascript is required. |
| Parent / Guardian Cell Phone | 4023800070 |
| 2nd Parent / Guardian Name | Kyla Blum |
| 2nd Parent / Guardian Email | Email hidden; Javascript is required. |
| 2nd Parent / Guardian Cell Phone | 3085309126 |
| Billing Address | 1155 Cottonwood Street Bennet, Nebraska 68317 United States Map It |
| Total | $250.00 |
| Payment Method | PayPal Checkout |
By submitting this I accept the terms of the aforementioned Waiver of Liability, Release, Assumption of Risk & Indemnity Agreement.