You must be aged 18+ to complete this form. Parents/Guardians must complete this form for anyone under the age of 18

Team / Activity Selection:

Gender:

First Name (required)

Surname (required)

Date of Birth: (in some browsers, reqd format is yyyy-mm-dd)

Nationality (required)

Ethnicity:

Player Address:




School Name (if applicable or N/A)

School Year as of Sept 2017 (if applicable or N/A)

Parent/Guardian Name (required)

Parent/Guardian Relationship:

Parent/Guardian Email (required)

Parent/Guardian Home Phone Number (required)

Parent/Guardian Mobile Phone Number (required)

Parent/Guardian Address:




Do you consider yourself to have a disability?

Other Details:
(Medical conditions, dietary requirements, allergies etc, if none add N/A)

Please advise if you have any objections to the player being included in promotional photography or videos relating to the club. Answer*:

I would like to receive updates about upcoming news and events and club information from City of Birmingham Rockets Basketball Club via,
SMSEmailTelephonePostI would not like to be contacted

Please bank transfer the correct amount for your membership to the following bank account with your name and team.

Account Name: City of Birmingham Basketball Club
Bank: HSBC
Account Number: 71487442
Sort Code: 40-32-03