| ELIGIBILITY (Admin-only) |
|
|---|---|
| Parent/Guardian First Name: | Ciara |
| Parent/Guardian Last Name: | Goodwin |
| Parent/Guardian Cell Phone: | 7573090392 |
| Email: | cgoodwin113@gmail.com |
| Player Information | |
| First Name: | Elijah |
| Last Name: | Brooks |
| Child Date of Birth | 03/23/2011 |
| JERSEY NUMBER | 10 |
| School: | Larkspur Middle |
| Grade: | 7 |
| Address: | 6655 Stoney Point Street |
| City: | Norfolk |
| State: | Virginia |
| Zip / Postal: | 23502 |
| Upload Player Headshot |  |
| Upload Government Issued ID |  |
| Emergency Contact | |
| Primary Emergency Contact Name: | Eric Person |
| Primary Emergency Contact Phone Number: | 7579017083 |
| Primary Emergency Contact Relationship to Player: | Dad |
| 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 |
