Team22 Bon Air Registration Posted December 30, 2014 by Matthew Athlete Name* First Last Athlete Age*Please enter a value between 5 and 20.Athlete Grade*Please enter a value between 1 and 12.Athlete SchoolParent/Guardian Name* First Last Phone*Email* Emergency Contact First Last Emergency PhonePayment*$125 per month - 5 month program - Pay per month or all at once 1 Month2 Months3 Months4 Months5 Months (Pay in Full)Register for Preseason (October Only) Yes Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Expiration Date Security Code Cardholder Name Accept Terms and Conditions*I, the parent/guardian listed above, give permission for the named athlete to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact named above, before taking this action. I will be financially responsible for any medical attention needed during Team22 Bon Air Practice or Bon Air Games or resulting from an injury received at Team22 Bon Air Practice or Bon Air Games I understand and agree to comply with the financial responsibility and commitment of the 5 month program, Team22 Bon Air. Payment will be made in full in the amount of $580.00 to Murrer22 Basketball. I agree to the terms and conditions below. This iframe contains the logic required to handle Ajax powered Gravity Forms.