Ensley Youth Sports Association Registration Form

1

Athlete Sport* This field is required.

CheerFootball

2

Athlete TeamBased On Age As Of August 1st

4

Athlete Name* This field is required.

First Name

Middle Name

Last Name

Suffix

5

Athlete Gender* This field is required.For Grant Purposes Only

MaleFemale

6

Athlete Ethnicity* This field is required.For Grant Purposes Only

Hispanic or LatinoNot Hispanic or Latino

7

Athlete Race / National Origin* This field is required.For Grant Purposes Only

8

Athlete Date Of Birth* This field is required.

Date

9

Athlete Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

10

Athlete School / Grade* This field is required.

11

Athlete Primary (1st) Jersey Number

12

Athlete Secondary (2nd) Jersey Number

13

Athlete Secondary (3rd) Jersey Number

14

Athlete Allergies / Medical Conditions* This field is required.

15

Does Athlete Require Inhaler or Epi Pen* This field is required.The inhaler or epi pen MUST BE brought to each practice and/or game and given to one of the coaches if needed

YesNo

16

Did Athlete Participate Last Season* This field is required.

YesNo

17

Which Park

18

New UniformNot Required If Purchased Last Year

YesNo

19

Primary Parent / Guardian Name* This field is required.

First Name

Last Name

20

Primary Parent / Guardian Email Address* This field is required.

example@example.com

21

Primary Parent / Guardian Cell Number* This field is required.

###-###-####

22

Primary Parent / Guardian Receive Texts* This field is required.

YesNo

23

Primary Parent / Guardian Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

24

Live With Primary Parent / Guardian* This field is required.

YesNo

25

Secondary Parent / Guardian Name* This field is required.

First Name

Last Name

26

Secondary Parent / Guardian Email Address* This field is required.

example@example.com

27

Secondary Parent / Guardian Cell Number* This field is required.

###-###-####

28

Secondary Parent / Guardian Receive Texts

YesNo

29

Secondary Parent / Guardian Address* This field is required.

Street Address

Street Address Line 2

City

State

Zip Code

Country

30

Live With Secondary Parent / Guardian* This field is required.

YesNo

31

Emergency Contact Name* This field is required.

First Name

Last Name

32

Emergency Contact Email Address* This field is required.

example@example.com

33

Emergency Contact Cell Number* This field is required.

###-###-####

34

Emergency Contact Receive Texts* This field is required.

YesNo

35

Code Of Conduct* This field is required.In order to place a check in the box, the Code Of Conduct MUST BE read in its entirety!

36

Electronic Signature* This field is required.By my electronic signature below, I certify that I have read, fully understand and accept all terms of the foregoing statement. Please signify your acceptance by entering your full name in the box below.

Clear

37

Payment Type* This field is required.

CashCredit

38

Payment Amount

39

Registration

0

Registration DepositNon-Refundable
$35.00+Edit
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Cheer Registration
$115.00+Edit
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Football Registration
$150.00+Edit
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Credit Card

First Name

Last Name