NORTH CAROLINA CONFERENCE OF TEMPLES AND COURTS

Ancient Egyptian Arabic Order Nobles Mystic Shrine

Of North and South America and Its Jurisdictions, Inc.

YOUTH DEPARTMENT

3 on 3 Basketball Tournament

REGISTRATION FORM

______________________________________ _______________________

TEMPLE OR COURT NAME NUMBER

______________________________________ ________________________

YOUTH DIRECTOR / DIRECTRESS NAME TELEPHONE #

ADDRESS CITY STATE ZIP CODE

PLEASE TYPE OR PRINT

Team name (capital letters):______________________________________

Status Circle One

10-12 13-14 15-17

1. ___________________________________

2. ___________________________________

3. ___________________________________

DEADLINE FOR ENTRY: May 15, 2010

Mail to: Noble Jimia Brantley (62)

1212 September Court

Fayetteville, NC 28314

910-635-1430