Mariemont Recreational Basketball
Online Registration Form for Winter 2010 Basketball

 
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Thank you for using the Mariemont Basketball Online Registration Form to register your daughter for Fall 2009/Winter 2010 basketball!

Instructions

To register your son or daughter for basketball, follow these steps:

  • Complete the form below and press the Submit Registration Button at bottom of the page. Fields in bold are required!
  • Once you press the Submit button you will be provided with a confirmation message for your registration that will provide a summary of your registration.

Player Information

Last Name 
(Child's) First NameParents - Please enter the Child's First Name - NOT Your first name!
Street Address 
City/Township 
State 
Zip
Phone Number()-- 
Alternate Phone Number()-- 
Gender: Male  Female  
(Child's) Birthdate:  Month     Day    Year   Player birthdate should be
on or after:   1991-08-01
on or before: 2002-07-31
Current Grade in School:Grade your son or daughter is School as of today.
Plays Up?Yes NoMy son or daughter usually plays up an Age Division.
E-Mail AddressA confirmation message will be sent to this e-mail address.
Alt. E-Mail AddressA confirmation message will be sent to your alternate e-mail address.
Parent's Names 
General CommentsEnter additional information or comments about the child in this area.

Emergency Contact Information

Emergency Contact Name 
Emergency Contact Phone 
Family Physician 
Family Physician Phone 
Medical CommentsList any known medical conditions or problems the coach should be aware of

Volunteer Information

Note: If you Volunteer as a Coach below you will be provided with a separate link at the end of the registration process to a Coach Registration Form... 
Volunteer As CoachCoach  Asst. Coach  Not Available 
Volunteer as Referee?Yes  No
Referee NameName of the person who is interested in volunteering as a Referee
General Volunteer?Yes  No
Other Volunteer InterestsPlease list any other interests or ways you might be able to volunteer.

Uniform Information

Jersey Size 
Short Size 
Sock Size 

Registration Fees

Fee ItemDescriptionFee
 Registration Fee for MRA Basketball
Registration Fee for MRA Basketball$65.00 
*** TOTAL *** $

Payment Information

Payment MethodCheck By Mail  Credit Card 
Name On CardEnter name exactly as it appears on your Credit or Debit Card
Credit Card Number   Enter Credit Card Number with NO spaces or dashes.
 All Credit Card information transmitted over a secure 256-bit SSL connection.
Card Expiration Date / Enter Credit Card expiration date (mm/yyyy).
Please make sure the billing address assigned to your credit card matches the billing address entered below.
Cardholder Street AddressEnter your billing Street Address for this Credit Card
Cardholder Zip CodeEnter your 5 digit billing Zip Code for this Credit Card
Credit Card CCV CodeEnter the 3 digit Card Card Validation Value located on the back of your credit card.

Health and Legal Disclaimers

Checking the box(s) below means you have read and accepted the agreement(s)

I, (Parent/Guardian), certify that my child is in good physicial condition, is fit to participate in the Mariemont Recreation Association Basketball Program and suffers from no physical impairment that might be aggravated by said participation. I certify that my child is covered by medical insurance, and that I will not hold Mariemont Recreation Association Basketball or it's represenatatives responsible for any injuries or harm to my child which occurs during participation in the program.
We, (Player & Parents/Guardians) further agree to abide by ALL Mariemont Recreation Association rules and to conduct ourselves in a sportmanlike manner during all Mariemont Recreation Association Basketball related activities. We further agree to abide by all directions and decisions of the referees, coaches, and officials of the Mariemont Recreation Association Programs. We realize that violations of the above are consequential and could result in our suspension for one (1) or more games.

  

Please press the Submit Button only once to avoid a duplicate registration. It takes just a couple of seconds to register. The next screen will provide information on where to send your check.

 

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