Shore Volleyball Academy - Winter Club Alternative Program Registration Form
Payment will be required for this registration to be confirmed and to save your athlete's spot in the program.

A response email may take up to 5 business days days upon completion of this form.
Email address *
Athlete Name: *
Your answer
Program: *
Those wishing to select a select a session with older athletes must email me at SempkowskiVolleyball@gmail.com to get approval- or you will be moved to your appropriate aged session.
Parent/Guardian Name: *
Your answer
Street Address *
Your answer
City: *
Your answer
State: *
Your answer
Zip Code: *
Your answer
Birthdate: *
MM
/
DD
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YYYY
Grade in 2019-20? *
Your answer
Should the athlete be restricted from athletic activities in any way? You must include any medical conditions that would require restricted participation. Must write "None" if so. *
Your answer
Parent Cell Phone #: *
Your answer
Secondary Email Address
Your answer
T-Shirt size: *
What school does the athlete attend this 2019-20 academic year? *
Your answer
Does the athlete currently play for a volleyball club? If so, which club?
Your answer
What is the primary position?
What is the secondary position?
How many years of past VB experience does the athlete have? *
Your answer
How did you hear about this program? *
I hereby give permission for my child to participate in this 2019-20 Shore Volleyball Academy Program. I certify that they are in good physical condition, have been examined within the last 12 months, and no medical reason has been found that they cannot participate in this program. Records show that all immunizations are up to date. I understand that they will be participating in rigorous play and activity. Clinic personnel have also been informed of any physical limitations, medications, or prior conditions. The program will safeguard the health of my child, but will not be responsible for accidents, injuries, or sickness on the way to volleyball, during volleyball, or on the way home. I agree that in the case of an accident involving my child while attending this program, and with full awareness that volleyball is an activity that may involve risk or injury, I release Dan Sempkowski, Shore Volleyball Academy, all the coaches, and host sites from any and all liability. I hereby request that my child be granted admittance into the 2019-20 Shore Volleyball Academy Clinic and authorize the directors to act on my behalf in the event of an emergency requiring medical attention. I will assume responsibility of payment for any such attention and have provided all necessary information. *
Parent please initial in agreement of the above statement. *
Your answer
Please select a payment option: *
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