Player Information
Player NameKason Blum
Player's Date of Birth04/07/2019
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 namesTeam 5 - Buresh
Player RegistrationPlayer 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 NameTom Blum
Parent / Guardian EmailEmail hidden; Javascript is required.
Parent / Guardian Cell Phone4023800070
2nd Parent / Guardian NameKyla Blum
2nd Parent / Guardian EmailEmail hidden; Javascript is required.
2nd Parent / Guardian Cell Phone3085309126
Billing Address1155 Cottonwood Street
Bennet, Nebraska 68317
United States
Map It
Total$250.00
Payment MethodPayPal Checkout