| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Mary |
| Parent/Guardian Last Name: | Moore |
| Parent/Guardian Cell Phone: | 7572022795 |
| Email: | Mooreinva@gmail.com |
| Player Information | |
| First Name: | Prince |
| Last Name: | Jordan |
| Child Date of Birth | 01/04/2011 |
| JERSEY NUMBER | 19 |
| School: | Larkspur Middle School |
| Grade: | 7 |
| Address: | 4815 Marlwood Way |
| City: | Virginia Beach |
| State: | Virginia |
| Zip / Postal: | 23462 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Mary Moore |
| Primary Emergency Contact Phone Number: | 7572022795 |
| Primary Emergency Contact Relationship to Player: | 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 |
