Lonnie Ray's Elite 3rd/4th Grade Boy's Registration  Spring/Summer 2021
3rd/4th Grade Boy's
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Email *
Player's  Last Name *
Player's First  Name *
Grade for Spring/Summer 2021 *
Date of Birth (MM-DD-YYYY) *
Home Address (Ex.. 1506 Brady St,)
City *
State *
Zip Code
Cell Phone (Format: XXX-XXX-XXXX)
School Name
Parents/Guardian (First and Last Name) *
Email Address *
Emergency Contact Name  (First & Last Name) & (Relationship) *
Emergency Contact Number  (Format: XXX-XXX-XXXX) *
Health Insurance *
Insurance Company Name
Insurance Company Card Holder Name
Insurance Company Policy Number
Dental Insurance *
Dental Insurance Company Name
Dental Insurance Policy Holder Name
Dental Insurance Policy Number
Medical Waiver/Release:  Lonnie Ray's Elite and any facilities,  where tryouts, practices, or games will be played will assume no liability for injury or damages arising from the results of the above named Athlete's participation unless due to the willful misconduct or gross negligence on the part of Lonnie Ray's Elite, it's affilliates or agents.  I hereby approve the above named Athlete, in the Lonnie Ray's Elite tryout program and consent to the emergency medical treatment for my child on my behalf.  To the best of my knowledge, there are no physical or other conditions which will interfere with my child's participation. *
Waiver of Liability and Promotion: Lonnie Ray's/Support A Kid Foundation INC. is not obligated to furnish any insurance under the Lonnie Ray's/Support A Kid Foundation INC.  program referred to above, although it may do so without obligation as to the adequacy, of any insurance it might furnish.  I the parent/guardian of the applicant agree that Lonnie Ray's/Support A Kid Foundation INC. and all individuals participation in Lonnie Ray's/Support A Kid Foundation INC. program in any capacity, ill not be liable for any causes of actions claims and injuries arising out of the participation of the applicant in Lonnie Ray's/Support A Kid Foundation INC. program, and hereby release all said individuals from such claim and liabilities.   *
The undersigned acknowledges that in all sports there certain risks of physical injuries and all players participate at their own risk.  I as legal parent/guardian of applicant, hereby consent to the participation of the applicant in Lonnie Ray's/Support A Kid Foundation INC. program under the above mentioned conditions.  I also agree to abide by the young athletes bill of rights.  I give my consent for this flyer to be photographed, videotaped, and/or filmed while participating in any Lonnie Ray's/Support A Kid Foundation INC.  activity and for the resulting photos, etc. ought to be used by Lonnie Ray's for educational and promotional purposes.  I have read and understand the above. *
Uniform Size *
T-Shirt Size *
Jersey Number (Top 3 Choices: 01, 23, 30) *
To submit this information, please provide your electronic signature to confirm submission                (First Name, Last Name) *
Notes
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