| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Brianni |
| Parent/Guardian Last Name: | Foxworth |
| Parent/Guardian Cell Phone: | 7578310358 |
| Email: | bsf507@gmail.com |
| Player Information | |
| First Name: | Tristan |
| Middle Name: | Antonio |
| Last Name: | Montgomery |
| Child Date of Birth | 01/06/2020 |
| JERSEY NUMBER | 0 |
| School: | Parkdale |
| Grade: | Pre k 4 |
| Address: | 321 Virginian de |
| City: | Norfolk |
| State: | Va |
| Zip / Postal: | 235050 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Tonya Deloach |
| Primary Emergency Contact Phone Number: | 7575531876 |
| Primary Emergency Contact Relationship to Player: | Grandmother |
| Medical History | |
| UPLOAD PROOF OF PHYSICAL |  |
| Does the player have any allergies that we need to be aware of? * | Yes |
| Does the player have any other medical conditions that we need to be aware of? * | Yes |
| If you answered yes please explain: | Seasonal allergies and mild asthma |
| REGISTRATION | REGISTRATION, Qty: 1, Price: $15.00 |
| Payment Method | PayPal Checkout |
