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MARTIN A. NONNENBERG
3 POINT SHOOT OUT


REGISTRATION FORM


HOLY ROSARY HALL
MARKET STREET, NORTH SCRANTON

NAME ____________________________________
ADDRESS ________________________________
CITY _______________STATE____ ZIP_______
PHONE _______-___________ SEX   M  F
DATE OF BIRTH___ /___ /___    AGE_______
PARENT/GUARDIAN NAME  ___________________
DOES YOUR CHILD TAKE ANY MEDICATIONS OR HAVE ANY MEDICAL CONDITIONS WE SHOULD BE AWARE OF?  NO_____ YES ______ PLEASE EXPLAIN.


DONATION     $5.00 ENTRANTS  FEE

PLEASE MAKE CHECKS PAYABLE TO:
“Martin A. Nonnenberg Tragedy Fund”
3105 North Main Ave.
Scranton, Pa. 18508

I HEREBY GIVE MY CHILD PERMISSION TO PARTICIPATE IN THE MARTIN A. NONNENBERG 3 POINT SHOOT OUT.  I UNDERSTAND THAT The Martin A. Nonnenberg 3 Point Shoot Out Tragedy Foundation  WOULD ASSUME NO RESPONSIBILITY FOR ANY ACCIDENTS OR INJURIES THAT MAY OCCUR THROUGHOUT THE TOURNAMENT.

PARENT/GUARDIAN  SIGNATURE__________________________________

DATE___/____/____




Any questions please call (570) 347-0808

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