| Parent/Guardian First Name: | Tiffany |
|---|---|
| Parent/Guardian Last Name: | Akers |
| Parent/Guardian Cell Phone: | 4347704516 |
| Email: | tiffanyakers91@gmail.com |
| Parent/Guardian 2 First Name: | Scott |
| Parent/Guardian 2 Last Name: | Akers, Sr. |
| Parent/Guardian 2 Cell Phone: | 4347702092 |
| Parent/Guardian 2 Email: | scottakers123@aol.com |
| Player Information | |
| First Name: | Scott |
| Middle Name: | JaMar |
| Last Name: | Akers, Jr. |
| Child Date of Birth | 04/09/2016 |
| JERSEY NUMBER | 11 |
| School: | Forest Hills Elementary |
| Grade: | 3 |
| Address: | 317 Withers Circle |
| City: | Danville |
| State: | VA |
| Zip / Postal: | 24541 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Tiffany Akers |
| Primary Emergency Contact Phone Number: | 4347704516 |
| Primary Emergency Contact Relationship to Player: | Mom |
| Secondary Emergency Contact Name: | Scott Akers Sr |
| Secondary Emergency Contact Phone Number: | 4347702092 |
| 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? * | No |
| REGISTRATION | REGISTRATION, Qty: 1, Price: $15.00 |
| Payment Method | PayPal Checkout |
