OFFICIAL ASSOCIATION PUBLICATION JANUARY/FEBRUARY 2013 EDITION
IN THE ZONE
See Page 15 for details on the warriors march supercamp
with daniel stow
THE HOT TOPIC
ZONE V MAN TO MAN DEFENSE
CONTENTS three Looking Through The Window FIVE The Ferriere Up There SIX Partnership Packages SEVEN Big V Roster Wrap eIGHT Big V Marquee Reps Announced NINE VJBL Corner Twelve Junior Hoop Star THIRTEEN Timeout FIFTEEN Supercamp SIXTEEN Chalk Talk NINETEEN Big V Memberships
In The Zone is designed and produced by Cat Advertising for Pakenham & District Basketball Association. For enquiries contact Catherine Rogers 0430 085 913 or email firstname.lastname@example.org On the cover: BIG V Star Jason Ferriere. (Jarrod Potter)
LOOKING THROUGH THE WINDOW ON... PLAYER CULTURE Warriors BIG V stalwart Bill ‘Window’ Winder took some time to explain his take on player culture and the direction of the Pakenham program. When I joined the Pakenham Warriors program in 2002, to be honest, I wasn’t sure what I wanted from basketball. I was 18 years old and a year off basketball had left a lot of open questions lingering. I wasn’t sure about what the Pakenham club would be like after having played in the large and successful Dandenong program throughout my junior career. The coach at the time was Danny Adamson, an American coach who preached ‘basketball intelligence’ and the need to develop strong ‘club culture’ over time. He spoke of how enthusiasm and encouragement can win games. Get a deflection, he used to say, and the whole defence can be ignited. He used to harp on how communication is important in basketball for success. This club culture is built over time as the players get to know each other both on, and off, the court. Pakenham has always had a decent club culture throughout the years playing in the MMBL and the Big V. The team had moderate success in the first two years we competed in the Big V, but we have had a constant flow of players in and out of the club, for whatever reason.
The downfall to last season was the personnel turnover. It really hurts the playing group when players and coaches are in and out, here one day, then gone the next. You find it hard to relate to the player and the person. Mouths start to drop and the losses are hard. Practices are a struggle for the people who really bleed Blue and Gold when there are some who are just making up numbers. This season is a different story to the last. We’ve seen the return of long standing personnel and new alike but there is a different feeling in the air. Coach Rogers is a no-fuss leader who tells it like it is: You need to trust your teammates 1 through 12 to support you, pull your head in on the practice court and also at game time. If you don’t, you’re going to hear about it from everyone. When some clubs have barely even had tryouts yet, our club has already been gelling as a unit during practices over the last eight weeks. However, it’s not just practices. Social outings, fitness sessions and soon a team pre-season camp gives us the opportunity to understand the ways each of our teammates work on and off the court. It seems we’re building a winning club culture at Pakenham and everyone is buying in. We know the fans will too because if we’re working as a unit within a structure, we will be having fun and winning. Players will stick around for the hard slog because they’ve been through it all together AND the games will be fun to watch. Pakenham is an exciting place to be for basketball. Let’s go Blue and Gold 2013!
The Ferriere up there Article By Jarrod Potter (Pakenham Gazette)
he biggest recruiting coup in Warriors’ history was unveiled this week, with college basketball and Big V Championship-experienced Jay Ferriere set to play for Pakenham. Ferriere, 28, from Narre Warren, spent four years at Manhattanville College, captaining the team, in the NCAA Division III competition after a successful time playing for Ringwood and Sherbrooke in the Big V. A true point guard, Ferriere is ready for the challenge of Big V basketball once again, after taking some time off following his four years at college. “Ryan contacted me and explained what the club was doing and I came down for myself and saw they’re building a good program,” Ferriere said. “They don’t really have a lot of assistance, and I wasn’t playing right now so I was more than happy to come down. “I like the direction they’re trying to go in and if I can help in any manner, then why not.” His college days – highlighted on-court by some top-25 rankings in the country and playing at Madison Square Garden – were significant for him to go to one of the biggest cities on Earth to ply his craft.
“I like the direction they’re trying to go in and if I can help in any manner, then why not.” “New York City, what can you say, it’s a lot different to Melbourne, Narre Warren and Pakenham,” Ferriere said. “Just that big Photo Courtesy of Pakenham Gazette
city living and just the freedom over there - it was a big stepping stone to go from a small suburb guy to the big city and part of the growing process and a great experience.” While posting wins is important to Ferriere, one of his other big aims with the Warriors is to see the whole basketball program flourish from juniors all the way up to the Big V ranks. “I’ve more signed on for development - the guys are great they’re lacking a little bit of direction. “Ryan has joined the program, and he knows what he’s talking about and will be great for them, but I thought some on-court leadership would help. “They’ve got some great young guys but lacked a mentor figure so that’s primarily my goal.” Pakenham coach Ryan Rogers said a player of Ferriere’s calibre will have an immediate effect on the side, but his off-court focus to helping the program is just as noteworthy. “He’ll have a major impact,” Rogers said. “When the proposition came about, I knew Jason from about 2003 when I was involved in the championship level – he was just an 18-19 year old kid, but even at that stage at Ringwood, he was on the horizon of good things. “For us to have him here, we’re over the moon. “He’s at a point of his life that he’s very comfortable, he could play basketball at a much higher level, but it’s about taking this program to some heights they haven’t seen yet.”
JAY’S PERSONAL highlights REEL
PARTNERSHIP PACKAGES - ‘Let’s Do It’ Over the past three seasons, the Pakenham Warriors have proven our players can hold their own against the best teams in the BIG V Basketball League. In 2013 we want to be a championship contender! We have exceptional community support. Do you want to be part of a successful, sustainable and exciting team?
(various packages to meet your needs)
WARRIORS BUSINESS NETWORK
(GOODS OR SERVICE With benefits tailored)
player partnerships $500
(become attached to one of our senior elite players)
game night partnerships
(promote your product to our passionate fans)
★ CLICK HERE TO VIEW VARIOUS PACKAGES ★
Contact Craig Magrath (President) Adrian Zemunik (Treasurer)
0437 511 312 0404 088 974
BIG V ROSTER WRAP The Warriors BIG V men have signed fifteen players – with nine returning from 2012, including league All Star nominee Sean Armstrong and the ever reliable Bill Winder. The Ryan Rogers era began with James Topp (pictured right) being announced as new team captain, while Jay Richardson joined his close friend from Blackburn and sharp shooter Aron Pantano has shown he can knock it down from the car park. The biggest and most anticipated signing to come was the coup of Jason Ferriere committing after 10 years involved at BIG V Championship and three years in the NCAA college system. Having two teams competing in the MMBL competition has allowed Rogers to test his structures in competitive situations and see his new charges in action which has been invaluable. The competition for spots will be red hot and a big emphasis has been on adjusting to having a structured game style. With some more senior guys coming onboard, the development of James Magrath, Sean Armstrong, Tim Bydder and Jake Heyen has been fast tracked as they have been pushed with quality opposition in training situations. Head Coach Ryan Rogers said that he is excited with what he has seen in the eight weeks training prior to Christmas but was disappointed with the loss of Daniel Jeavons who has opted to have a break in 2013. The team have already scheduled five pre-season games which will be announced in the new year and a team pre-season camp has been booked for February 8-10 at The Summit in Gippsland. “The age profile was something that I wanted to address immediately with a number of guys quite young (18-20yrs) and a few at the other end of the spectrum (29-32yrs) so all the guys I have brought in fit perfectly between that bracket and more importantly add great value positionally to the returning crew. The roster we’ve put together has a strong influence of guys who individually have a point to prove, we will be much deeper than the 2-18 squad of 2012 and finals are a must with the pickups we’ve acquired” said Rogers. DEPARTED PLAYERS – Bayi Handy (Released), Aaron Olczyk (Released), Daniel Jeavons (Resting), Tyson Harding (Released) RETURNING PLAYERS – Bill Winder, Tim Bydder, Tim Eakins, Sean Armstrong, James Magrath, Jake Heyen, Daniel Stow, Craig Drew, Charlie Taualii NEW PLAYERS – James Topp (Warrandyte), Jason Ferriere (Ringwood), Jay Richardson (Blackburn), Aron Pantano (Redlands), Savin Lopez, Leon Stapley (Retirement)
CLICK HERE FOR JAMES TOPP ANNOUNCEMENT
CLICK HERE FOR ARON PANTANO ANNOUNCEMENT
CLICK HERE FOR SEAN ARMSTRONG ANNOUNCEMENT
CLICK HERE FOR BILL WINDER & TIM EAKINS ANNOUNCEMENT
CLICK HERE FOR DANIEL STOW ANNOUNCEMENT
BIG V MARQUEE REPS ANNOUNCED A major part of taking a ‘one association’ approach is to have the Warriors senior players involved with the stars of tomorrow and the PDBA are committed to engaging our BIG V players with each of the VJBL teams where they will act as mentors in 2013. Throughout the year the assigned players will attend training sessions and Friday night games for their team offering guidance and support aimed at further strengthening our strong family culture.
Under 12 Girls: Leon STAPLEY
Under 16 (1) Boys: Aron PANTANO
Under 12 Boys: James TOPP
Under 16 (2) Boys: Jay RICHARDSON
Under 14 Girls: Tim BYDDER
Under 16 (3) Boys: Jake HEYEN
Under 14 (1) Boys: James MAGRATH & Jay FERRIERE
Under 18 (1) Girls: Tim EAKINS
Under 14 (2) Boys: Sean ARMSTRONG
Under 18 (2) Girls: Charlie TAUALII
Under 16 (1) Girls: Bill WINDER
Under 18 (1) Boys: Daniel STOW
Under 16 (2) Girls: Craig DREW
Under 18 (2) Boys: Savin LOPEZ
corner On Friday 23rd November, grading began with a record number of 14 junior Warriors teams taking to the floor for the 2012/13 VJBL season. The VJBL grading system is quite complex, but provides a comprehensive assessment of every team to ensure they end up in a competitive division for the actual season. Grading consists of two phases: Phase 1 (Pre Christmas) - teams play in an assigned pool of four teams, with each team playing each other once, plus one round of additional “crossover” games. Based on phase 1 results, all teams are resorted into new pools for phase 2. Phase 2 (starting Feb 2013) - teams again Coach Jordan Eagles and the U/12 Warriors Girls play in pools of four, followed by a crossover game to sort teams into their final divisions for the regular season. Every age group has a grading map that shows the progress of teams through the grading phases. The grading system is quite complex, but it is probably the most comprehensive system in Australian junior basketball and works an absolute treat to make sure teams play in a division that matches their level of play. Following phase 2 of grading, all teams will have been assigned into a division for the main season which begins on Friday 1st March, 2013. We’ll report further on how all our teams are progressing through grading in our next edition - good luck to all teams for the new season.
FOR GRADING PHASE 2 FIXTURES
For all your Australia Day Tournament information CLICK HERE
the current landscape TEAM Under 12 Girls Under 12 Boys Under 14 Girls Under 14 (1) Boys Under 14 (2) Boys Under 16 (1) Girls Under 16 (2) Girls Under 16 (1) Boys Under 16 (2) Boys Under 16 (3) Boys Under 18 (1) Girls Under 18 (2) Girls Under 18 (1) Boys Under 18 (2) Boys
81 101 72 22 104 86 114 69 133 145 55 66 64 118
Pool 5 Pool 6 Pool 4 Pool 1 Pool 6 Pool 5 Pool 7 Pool 7 Pool 8 Pool 9 Pool 3 Pool 4 Pool 4 Pool 7
Pool DD Pool DD Pool CC Pool AA Regional 5 Regional 1 Regional 3 Pool DD Regional 4 Regional 7 Pool CC Pool DD Pool CC Regional 4
Highest Competition Possibility VJL 2 VJL 2 VJL 1 VJ Championship Regional Regional Regional VJL 4 Regional Regional VJL 1 VJL 4 VJL 1 Regional
THE HOT TOPIC
We commend all coaches for taking up such an important role in developing the children! Now, one of the most-debated topics is what defense should we teach young players? Zone or Man? The answer is without a doubt man-to-man defense! I can promise you that in the long-run, you will develop better basketball players by playing man to man defense. You may not win as many games at first, but I guarantee you start winning more games as the season progresses as long as the man to man defensive principles are properly taught. The feeling of seeing players succeeding at higher levels, because of the foundation you set as a coach is so much more rewarding than winning a few more games at the junior level. In a zone defense, players tend to just watch the ball and are reactive to the oppositions ball movement where as in a man to man defence they have to be aware of both their man and the ball. They can take teams out of their comfort zone and learn good defensive principles in order to be successful! As these young players get older, all of the sudden these bad defensive habits get exposed because kids are bigger, stronger, more coordinated, and more skilled. The questions you must ask are, can your players guard the ball one on one, can your players be relied to provide help once his teammate is beaten... work towards it! Download FREE coaching e-books by clicking on the e-book icon. A great coaching resource is www.breakthroughbasketball.com
WARRIORS ONLINE HOME REVAMPED
We have restructured our online home to include all programs and branches of the association in one location. While the site will be a work in progress it will provide the public with all the latest news, fixtures, results, statistics, upcoming events, photos, player profiles and the highly anticipated Warriors TV. The goal is to crack 15,000 page requests each month so spread the word as this can play a crucial role in the club sourcing new sponsors. If there is something that you would like to see included on the website please email Ryan Rogers at - email@example.com
junior HOOP STAR NAME: Cody Fredrickson AGE: 12 DOMESTIC TEAM: High Flyers VJBL TEAM: Warriors U/14 (1) Boys PROUDEST ACHIEVEMENT: Winning Team MVP for Warriors VJBL in 2011 (U/12) & 2012 (U/14) Q&A What are your goals or ambitions within basketball? To Make it to the Highest Possible Standard that I can Why do you play basketball? It’s my passion Which basketball team(s) do you support? Miami Heat & Melbourne Tigers Who is your favourite player(s)? Lebron James and Kevin Durant What is the most number of points you have scored in a game? 34 What position do you play? Point Guard How many years have you been playing? 7 Do you have any hobbies outside of basketball? Riding my Scooter IF YOU WOULD LIKE TO NOMINATE A ‘HOOP STAR’ OF THE MONTH SIMPLY SEND THE PERSON’S NAME, CONTACT DETAILS AND THE REASON FOR YOUR NOMINATION TO - firstname.lastname@example.org
Name: Braden Venning Team(s) Coached: Warriors U/16 (1) Boys, Domestic - U16 Boys Pythons, U16 Girls Blue Angels Q & A: Nickname? Bradumbledore, Coach, B-Man Years Coaching? 2nd Year Representative, 6 Years Domestic Coaching Favourite Food? Chicken Parma Favourite Drink? Beer or Coke in a Glass Bottle. Biggest Influence? The Coaches I’ve Had Through All my Years of Basketball. Job Away From Coaching? Integration Aide At a Primary School. Favourite Drill? Boston Layups If I was a superhero, I’d be? Batman, Always be Batman. Greatest Achievement? Getting Picked For The State Team in Year 7. If I were to host a T.V show, I’d host? Something Really Awesome With Flips or When Animals Attack. That Would be Cool. Personal Motto? Hard Work Beats Talent, When Talent Fails to Work Hard. Why do you Coach? I Enjoy Working With Kids and Had Some Really Good Coaches Growing Up so I Wanted to be That Guy for These Kids. What type of Coach are you? A Positive, Hands on Coach. I Take Part in Most of the Drills and Show Them How to do it or Refine Their Skills.
TIMEOUT GETTING TO KNOW... •••• •••• •••• Daniel •••• •••• •••• •••• •••• STOW
Height: 193cm Weight: 91kg Age: 29 Number: 9 Proudly Sponsored By: AVAILABLE
Years At Pakenham: 18 Years Recruited From: Pakenham Juniors Nickname: Stowie & Austin Occupation: Systems Support Favourite Playing Venue: Dandenong Childhood Hero: Batman Shoe Size & Make: 13, Nike Favourite Food: Pasta Favourite Drink: Coffee... Lots of Coffee Favourite Movie: Original Star Wars Trilogy
Favourite TV Show: Survivor Favourite Group/Artist: Mindsnare What Would You Spend Your Last $20 On: Breakfast Three Dream Dinner Guests: The Rock, Brandon Roy & Dustin Martin Pre-Game Superstition: Deep Heat & Lots of Fluids What Do You Look Forward To Most This Season: Winning!
career statistics GAMES PTS
59 5.2 34.1 33.2 2.8 1.1
join our community!
the voice of reason
Name: Craig Magrath Q & A: Specific Role: President Nickname: Calfie Years Involved in PDBA: 25+ Years Years on PDBA Committee: Five Favourite Food: Rice & Raw Fish Head Favourite Drink: Chateau Carlton Favourite TV Show: The Sullivans Favourite Movie: The Matrix Who is the hardest to get a word in front of around the table: No-one...now! What is Pakenham Basketball currently doing well? Expanding the Junior Warrior teams. Why are you on the Committee: Sometimes I ask myself that...but in reality, trying to make a positive difference to our club! What challenges does Pakenham Basketball face in the short term? Income & Sponsorship
Committee Member profile
SUPERCAMP e r e i r r e F n o s a #1 J WITH
Come and join the Warriors star Point Guard Jason Ferriere along with other Big V Warriors players, develop skills and improve your basketball knowledge in a enjoyable and rewarding environment.
Where Cardinia LiFE, Pakenham When Tuesday 5th & Wednesday 6th March 2013, 9.30am til 3.30pm Cost $30 per day or $50 for both days. More details to come in the coming month - stay tuned!
want more info? CLICK HERE TO REGISTER YOUR INTEREST ABOUT CAMP LEADER Date of Birth 7/1/1984 Position
Weight 86kgs University
College ‘08-11 CAREER • Ringwood Hawks Big V Championship Men • Sherbrooke Suns Big V Division 1 Men • Manhattanville Valiants NCAA Division III
· 2002 Big V Debut (Ringwood) · 2006 Big V Division 1 Championship (Sherbrooke) · 2008-2011 Team Captain (Manhattanville) · 2009-2011 MAC Academic Honor Roll (Manhattanville) · 2008/09 Team Leader, 134 Assists Inc. 13 In A Single Game (Manhattanville) · 2010/11 Team Leader, 127 Assists Inc. 11 In A Single Game (Manhattanville)
chalk talk game preparation How often do we hear coaches say “turn up ready to play!”? This can mean so many things when you think of our sport and all of the various aspects involved in the game. Hopefully the following information will be helpful in your pre-game preparation and you will impress your coach and teammates. Players: For senior players who must turn up an hour before their matches, the opportunity to focus on the coach’s game plan and scouting report is greater for you as it is usually written on the whiteboard in the locker room. Junior players do not have that luxury so it is imperative that you really think about what you need to do on the ride to the game and once you enter the stadium. A few things to keep in mind would be, knowing the offence your team runs, what type of defense your team plays, things your coaches taught you during the trainings that week, and what things worked well/did not work well for you the last time you played. Once warm ups start it is important to make shots as well as breaking a sweat; If you are struggling to make shots with no defense on the court, then you will more than likely struggle once the game starts. When the game starts you should not be leaning back relaxed on the bench. You should be sitting forward paying attention to how the game is being played and how the referee’s are making calls. If you can see yourself contributing to the team as you wait to play, then you will be more likely to do better than the player who sits back laughing and not focusing on the game. Coaches: Coaches have just as much responsibility (if not more) as a player to “turn up ready to play!” You are to know your game plan and how each one of your players fit into it. This can differ depending on the opposition team each week so you should have some pre-planned adjustments you can make if things do not go to script. This could be different lineups, substitution patterns, and different play options. During warm ups it is a good idea to focus on how well your players are warming up. If they are “mucking around” or aren’t demonstrating the intensity you consider appropriate pull them up right away!!!
A poor warm up is a recipe for disaster when the game starts! It’s also important to have a look at how the other team is warming up to see who is making shots, how organised their warm up is (which is usually a sign of a well/poorly coached team), and to pick up on any tendencies the players have (left-handed, righthanded). When the game starts, so does the adjustment phase of your coaching. If you are focusing too much on the officials, then you have lost focus on your team and you have lost your edge to “be ready to play!” If you are well prepared and you have prepared your team, then everything will take care of itself.
Even if you are disappointed by the result, please be a good role model and shake hands with the opponents and the officials. Try to keep post-game speeches general and not player specific (unless it is complimentary). Parents: The contribution of a parent to the readiness to play of their young athlete can be very simple if the following suggestions are followed:
1) Make sure you try to get your child to the match venue as early as possible. Anxiety over being late may cause the child; his/her team mates and their coach to lose focus.
2) Try to keep your ideas of what your child or his coach and teammates “should” be doing to yourself. Your information may very well be accurate, but it may be the exact opposite of what the coach has asked of your young player.
3) During the match if you don’t have anything nice to say, then don’t say anything at all! If you do not think that obnoxious behavior affects the way your child and the team perform, then you are sadly mistaken.
After the match please do not try to discuss playing time or tactics with the coach. If you wish to discuss these things then appropriately approach the coach before training or make a phone call before the teams next training session. If you are not satisfied with the response then there is a formal issue resolution process that should be followed and junior coaching director Craig Magrath is the relevant contact in that situation. 4) Support your child’s performance whether you believe they played well or not. I often hear that a coach is taking a players’ confidence because they are not playing them. That may be partially true. Negative feedback from a parent (whether it is about the player or the coach) may cause more damage as the burden of care weighs more heavily on the parents. Try to learn and help the child learn from the situation rather than trying to control and alter the experience.
In closing, there are a lot of different things that surround a child “being ready to play!” If everyone does their part, then there is a greater opportunity for the child to grow and develop into a leader and establish a solid foundation for work ethic. We are a club on the rise and get great support from our parents. Keep up the good work and I challenge you all to take the steps to “be ready to play!”
BIG V PRE-SEASON SCHEDULE
During February and March the BIG V Division 2 Men will be partaking in a number of pre-season games as they near their regular season and would love to see the stands full. Come out and support the new look Warriors with entry just a gold coin donation.
Warriors V Casey Cavaliers When and Where: Saturday 16th February 2013, ‘The Colosseum’ (Cardinia LiFE) Tip-Off: 4:00pm Warriors V Coburg Giants When and Where: Sunday 17th February 2013, ‘The Colosseum’ (Cardinia LiFE) Tip-Off: 1:00pm Warriors V Latrobe City Pacers When and Where: Saturday 23rd February 2013, Moe Basketball Stadium Tip-Off: 7:00pm Warriors V Chelsea Gulls When and Where: Sunday 24th February 2013, ‘The Colosseum’ (Cardinia LiFE) Tip-Off: 1:00pm Warriors V Maccabi Warriors When and Where: Thursday 28th February 2013, Bialik Stadium Tip-Off: 8:00pm BIG V Pre-Season Tournament When and Where: Saturday 9th-Monday 11th March 2013, Frankston Basketball Stadium
2013 Big V Membershi p Pri c es ★★★★★★★★★
Full Season Membership Package
Family A Family B
Family A 3 Adults & 3 Children Adult 18 years and over Family B 3 Adults & 2 Children Child 4-17 years old Family C 3 Adults & 1 Child Value based on standard entry price to 9 home games ($5 adult, $2 child)
HIPS MEMBERST PASS Y IL M A F L L U AL BONUS AD A INCLUDE A TO BRING ALONG O U T O Y R E R K FO R CO-WOR FRIEND O HOME GAME EVERY
Membership Entitlements • • • • • • •
Your very own membership card allowing entry to all BIG V Men’s home games including finals Invitation to all club events Receive an emailed version of the Pakenham & District Basketball Newsletter - ‘In The Zone’ Receive a letter from Captain James Topp personally welcoming you onboard Receive 10 % Discount to all Warriors Holiday Camps Monthly draw to have your favourite Warrior run a 1 hour clinic for you and nine friends Go into the draw to be the team mascot for a BIG V home game and participate with the Warriors in pre-game
Membership Form Please complete form and return with your payment to: Pakenham & District Basketball Association, Treasurer - Adrian Zemunik, PO Box 370, Pakenham VIC 3810 or see Adrian in person at any Warriors Pre-Season game OR Sunday Morning Training to make payment. I would like to purchase the following membership/s (tick box): Family A (3 Adults & 3 Children) Adult (18 years and over) Family B (3 Adults & 2 Children) Child (4-17 years old) Family C (3 Adults & 1 Child) VJBL Discount Applies TOTAL: $ ____________________________________ SURNAME: __________________________________ GIVEN NAME: ________________________________ Street Address: __________________________________________ Postcode: _______________ Phone (Home): _______________________________ Email: _____________________________________________________________________________ Family Membership Only: Please list all names and birthdates for members included on your Family Pass (D.O.B. Only Applicable For Children) 1) ________________________________ D.O.B: ____ /____ /_______ 2) ________________________________ D.O.B: ____ /____ /_______ 3) ________________________________ D.O.B: ____ /____ /_______ 4) ________________________________ D.O.B: ____ /____ /_______ 5) ________________________________ D.O.B: ____ /____ /_______ 6) ________________________________ D.O.B: ____ /____ /_______
OFFICE USE ONLY: Payment received by:
Date: ____ /____ /_______