| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Rachelle |
| Parent/Guardian Last Name: | Bailey |
| Parent/Guardian Cell Phone: | 7579569378 |
| Email: | rachellebailey04@gmail.com |
| Parent/Guardian 2 First Name: | Kevin |
| Parent/Guardian 2 Last Name: | Walker |
| Parent/Guardian 2 Cell Phone: | 7572905458 |
| Parent/Guardian 2 Email: | kevinw517@gmail.com |
| Player Information | |
| First Name: | Kayden |
| Middle Name: | Amari |
| Last Name: | Pinnock |
| Child Date of Birth | 12/13/2015 |
| JERSEY NUMBER | 4 |
| School: | Lindenwood elementary |
| Grade: | 3 |
| Address: | 2315 Lafayette blvd |
| Address 2: | Apt a |
| City: | Norfolk |
| State: | Va |
| Zip / Postal: | 23509 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Roger blow |
| Primary Emergency Contact Phone Number: | +1 (757) 343-5922 |
| Primary Emergency Contact Relationship to Player: | Uncle |
| Secondary Emergency Contact Name: | Tasha glover |
| Secondary Emergency Contact Phone Number: | +1 (757) 761-8464 |
| Medical History | |
| UPLOAD PROOF OF PHYSICAL |  |
| Does the player have any allergies that we need to be aware of? * | No |
| Does the player have any other medical conditions that we need to be aware of? * | Yes |
| If you answered yes please explain: | Asthma |
| REGISTRATION | REGISTRATION, Qty: 1, Price: $15.00 |
| Payment Method | PayPal Checkout |
