| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Audris |
| Parent/Guardian Last Name: | Johnson |
| Parent/Guardian Cell Phone: | 3578838488 |
| Email: | Johnsonaudris@gmail.com |
| Player Information | |
| First Name: | Xavier |
| Last Name: | Johnson |
| Child Date of Birth | 08/02/2010 |
| JERSEY NUMBER | 56 |
| School: | Ruffner Middle School |
| Grade: | 7 |
| Address: | 966 Denhart st |
| City: | Norfolk |
| State: | Virginia |
| Zip / Postal: | 23504 |
| Upload Player Headshot |  |
| Upload Government Issued ID | |
| Emergency Contact | |
| Primary Emergency Contact Name: | Audris Johnson |
| Primary Emergency Contact Phone Number: | 3578838488 |
| Primary Emergency Contact Relationship to Player: | Parent |
| 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 |
