Age
Name
Date of Birth
Address
Sex: (M/F)
Graduating
Class :
(ex: 2012)
Cell:
Phone:
E-Mail
School
Position
Height
Shirt Size
Weight
Payment Method (Cash/Check)
Please send prior to week of Oct. 22
Make Payments to:  

Steve Brodzinski
312 McCully St.
Pittsburgh, PA 15216
_____________________________________________________________________________________________________
I understand that I am enrolling my child in the Pittsburgh Basketball Report Showcase or affiliated
program, and that Pittsburgh Basketball Report LLC, Coach Steve Brodzinski, Coach Daryn Freedman,
The Kiskiminetas Springs School, or any coaches or facilities used, will not be liable for any injuries
incurred during participation in the program. I also understand that there are no refunds!

Signature of Parent/Guardian:  __________________________________    Date: _______________

Check The Box If You Agree To The Above Waiver:
Pittsburgh Basketball Report

Best of Pittsburgh Fall Showcase  -
Saturday October 29th

Registration Form - *All required fields