2017-2018 Registration Form
This information will be used for your athlete's 2017-2018 season. All information must be complete and accurate.
Email address *
Athlete First AND Last Name *
Your answer
Athlete Address *
Your answer
Athlete Phone Number *
Your answer
Athlete Age as of August 31, 2017 *
Your answer
Athlete Grade Level 2017-2018 School Year *
Your answer
Athlete Birthday *
MM
/
DD
/
YYYY
Parent/Guardian Name *
Your answer
Parent Contact Number *
Your answer
Parent Email Address *
Your answer
Parent Name
Your answer
Parent Contact Number
Your answer
Parent Email Address
Your answer
Emergency Contact Name (Other than Parents) *
Your answer
Emergency Contact Phone Number *
Your answer
Health Insurance Carrier *
Your answer
Policy/Group Number *
Your answer
Any intolerance to drugs or medication? *
If "Yes" please describe, if "No" please write "None" *
Your answer
Any previous illness, condition, disability or injury the gym staff should be aware of? *
If "Yes" please describe, if "No" please write "None" *
Your answer
Please list any medications our child is currently taking: *
Your answer
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. *
Please type your name below acknowledging you agree to the above statement. *
Your answer
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