| Parent/Guardian First Name: | LaNita |
|---|---|
| Parent/Guardian Last Name: | Johnson |
| Parent/Guardian Cell Phone: | 3367382469 |
| Email: | lanita.johnson@gmail.com |
| Player Information | |
| First Name: | Josiah |
| Last Name: | Johnson |
| Child Date of Birth | 11/08/2017 |
| Grade: | K |
| Address: | 5851 Allison rd |
| City: | Pelham |
| State: | NC |
| Zip / Postal: | 27311 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Lawrence Johnson |
| Primary Emergency Contact Phone Number: | 3365141901 |
| Primary Emergency Contact Relationship to Player: | Father |
| 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: | Josiah is allergic to dust and pollen. When he runs a lot sometimes it hurts his chest and is hard on his breathing. We think it’s from his lack of physical exercise. We have an appointment in August to check out the issue. |
| REGISTRATION | REGISTRATION, Qty: 1, Price: $15.00 |
| Payment Method | PayPal Checkout |
