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2022-2023 VALLEY PREP & ELITE REGISTRATION FORM
This information will be used for the 2022-2023 season. All information must be complete and accurate.
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Athlete FIRST name *
Athlete LAST name *
Athlete Address *
Athlete Phone Number
Athlete Age *
Athlete Birthday (EX: 02/26/1971) *
Athlete BIRTH YEAR *
Athlete T-shirt size (please state adult or youth) *
Parent/Guardian Name *
Parent/Guardian Contact Number *
Parent/Guardian Email Address *
Emergency Contact Name (Other than Parents) *
Emergency Contact Phone Number *
Health Insurance Carrier
Policy/Group Number
Any intolerance to drugs or medication?
Clear selection
If "Yes" please describe, if "No" please write "None"
Any previous illness, condition, disability or injury the gym staff should be aware of?
Clear selection
If "Yes" please describe, if "No" please write "None"
Please list any medications our child is currently taking:
Please list any allergies.
I will allow Valley staff to provide my child with the following medications: (Check all that apply) *
Required
I give my athlete (named above) permission to participate in athletic and related activities to be conducted by Valley Elite All Stars. To my knowledge my child has no physical restrictions that would inhibit her/him from this activity. I further acknowledge and understand that I am assuming the risk of such physical illness, injury or even death that my child may sustain from this activity. In the event that my child is injured, needs immediate medical attention, and I cannot be reached, I give Valley Elite All Stars permission to authorize transportation to the nearest medical center for medical attention and I will assume the costs of such transportation and medical attention. *
Photo/Video Release Form:I hereby give Valley Elite All Stars irrevocable right to use my child’s name, picture, photograph, video, or any other depiction(s) thereof or likeness in all forms of media and in all manners including composite or other representation, for advertising, trade, or any other lawful purpose, and I waive the right to inspect or approve the finished product, including copy that may be created in connection therewith. I also waive any rights to compensation or ownership thereto. I have read this release and I am fully familiar with its contents and competent to make this release. I agree to hold harmless Valley Elite All Stars from any claims for damage, libel, slander, or invasion of privacy. *
Please type your name below acknowledging you agree to the above statements *
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