| Parent/Guardian First Name: | Jerika |
|---|---|
| Parent/Guardian Last Name: | Barley-Bey |
| Parent/Guardian Cell Phone: | 434-429-7566 |
| Email: | jbarleybey@gmail.com |
| Player Information | |
| First Name: | Naji |
| Last Name: | Barley |
| Child Date of Birth | 08/09/2016 |
| JERSEY NUMBER | 2 |
| Grade: | 3 |
| Address: | 123 Kings Ct |
| City: | Danville |
| State: | VA |
| Zip / Postal: | 24540 |
| Upload Player Headshot |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Jerika Barley-Bey |
| Primary Emergency Contact Phone Number: | 434-429-7566 |
| Primary Emergency Contact Relationship to Player: | Parent |
| Secondary Emergency Contact Name: | Steven Thornton/Claudia Woods |
| Secondary Emergency Contact Phone Number: | 434-203-6538/434-429-1568 |
| Medical History | |
| UPLOAD PROOF OF PHYSICAL | BarleyPhysical.pdf |
| 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: | Allergic to Amoxicillin. History of Kidney Cancer. Has single Kidney. |
| REGISTRATION | REGISTRATION, Qty: 1, Price: $15.00 |
| Payment Method | PayPal Checkout |
