| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Emilia |
| Parent/Guardian Last Name: | Diaz |
| Parent/Guardian Cell Phone: | 7572141877 |
| Email: | emiliadiaz0423@gmail.com |
| Player Information | |
| First Name: | Jamontae |
| Last Name: | Spence |
| Child Date of Birth | 04/18/2011 |
| JERSEY NUMBER | 12 |
| School: | Blair Middle School |
| Grade: | 7 |
| Address: | 304 Walker Ave |
| City: | Norfolk |
| State: | Virginia |
| Zip / Postal: | 23523 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Jermaine Spence |
| Primary Emergency Contact Phone Number: | 7572142703 |
| 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? * | 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 |
