| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Cheetara |
| Parent/Guardian Last Name: | Williams |
| Parent/Guardian Cell Phone: | (757) 228-2845 |
| Email: | Vatribeorganization@yahoo.com |
| Player Information | |
| First Name: | Reginald |
| Last Name: | Smiley IIi |
| Child Date of Birth | 03/08/2012 |
| JERSEY NUMBER | 5 |
| School: | Brighton Elementary |
| Grade: | 6 |
| Address: | 501 Jefferson Street Apt I |
| City: | Portsmouth |
| State: | Virginia |
| Zip / Postal: | 23704 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Reginald Smiley |
| Primary Emergency Contact Phone Number: | 7572925958 |
| 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 |
