| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Keith |
| Parent/Guardian Last Name: | Brown |
| Parent/Guardian Cell Phone: | 7575280827 |
| Email: | VatribeOrganization@yahoo.com |
| Player Information | |
| First Name: | Tyrell |
| Last Name: | Benton |
| Child Date of Birth | 09/29/2010 |
| JERSEY NUMBER | 1 |
| School: | Craddock Middle School |
| Grade: | 7 |
| Address: | 501 Jefferson Avenue |
| City: | Chesapeake |
| State: | Virginia |
| Zip / Postal: | 23704 |
| Upload Player Headshot |  |
| Upload Government Issued ID | IMG_1071.heic |
| Emergency Contact | |
| Primary Emergency Contact Name: | Adrienne Brown |
| Primary Emergency Contact Phone Number: | 7578376900 |
| Primary Emergency Contact Relationship to Player: | Step mother |
| 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 |
