The Michigan Blind Athletic Association

28th Annual USABA Midwest Regional John Bakos Memorial Goalball Tournament

Please submit one entry form per team/pool player.

Important: The application fee of $40 for each player and coach is necessary to guarantee your team's application)

Team name:

Gender:

Male Female

Player Information

NOTE: EVERY TEAM MEMBER, INCLUDING COACHES, MUST BE A 2012 MEMBER OF USABA. - (Does not apply to international athletes). Use the link above to register or renew online.

	Player Name	Visual Classification	USABA Member	Jersey No.	T-shirt Size
1.
2.
3.
4.
5.
6.

Coaches (up to 3)

	Coach Name	USABA Member	T-shirt Size
1.
2.
3.

Contact Information

Contact Name:

Address:

Address cont.:

City:

State/province:

ZIP/postal code:

Phone:

Cell:

Email:

Do you want a pool player if available?

Yes No Maybe

Do you require transportation?

Yes No

Please leave any additional comments below.

Send checks made out to: (MBAA) Michigan Blind Athletic Association to the below address (applications will be accepted via E-mail, but an application fee is necessary to guarantee your team's application)

Mail checks to:
Cassandra Dickson
2520 Springmont Ave
Kalamazoo, MI 49008
Place "GB" and the team/player name the memo.

Please direct all questions to the Tournament Director:
Jill Redfield
(734) 223-6548
jillredfield1@gmail.com

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