Athlete Registration Form

MEDICAL INSURANCE, HEALTH & CONSENT INFORMATION
YesNo
If YES, enter name of MEDICAL INSURANCE Carrier:

Insurance Company NameGroup/Policy Number
Or upload copy of insurance card:

Please upload front and back of insurance card.
Cancelof
PRIMARY CARE DOCTOR/PHYSICIAN

First NameLast Name
PRIMARY CARE DOCTOR/PHYSICIAN Address

Street Address

Street Address Line 2

CityState

Zip Code
DOCTOR/PHYSICIAN Phone Number
Format: (000) 000-0000.
DOCTOR/PHYSICIAN E-MAIL Address:
example@example.com
List any or all your Child's HEALTH/MEDICAL HISTORY:*
List any physical and mental issues (Ex: allergies, asthma, diabetes, etc.). If None, Type "NONE."
List any or all your Child's History of INJURIES or HOSPITALIZATION(S):*
If None, Type "NONE."
List any or all your Child's MEDICATIONS and DOSAGES taken on a continual basis*
If None, Type "NONE."
List any or all your Child's Health Condition that REQUIRE(S) ATTENTION during any sports activity:*
If None, Type "NONE."

WAIVER AND RELEASE OF LIABILITY*
FINANCIAL RESPONSIBILITY AGREEMENT*
Signature

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By signing above, I understand that (i) electronically signing and submitting any document(s) to 58 Sports legally binds me in the same manner as if I had signed in a non-electronic form, and (ii) the electronically stored copy of my signature, any written instruction or authorization and any other document(s) provided to me by 58 Sports, is considered to be the true, accurate and complete record, legally enforceable in any proceeding to the same extent as if such documents were originally generated and maintained in printed form. I agree not to contest the admissibility or enforceability of 58 Sports' electronically stored copy of this Athlete Registration and any other documents. By using the System to electronically sign and submit any document, I agree to the terms and conditions of this Consent.

2024 Summer Sports Training Schedule

58 SPORTS LLC
St. Paul VI Catholic High School

42341 Braddock Rd, Chantilly, VA 20152
June 17 - 21, 2023 (4 pm - 5:15 pm)June 24 - 28, 2023 (4 pm - 5:15 pm)July 1 - 5, 2023 (4 pm - 5:15 pm)July 8 - 12, 2023 (4 pm - 5:15 pm)July 15 - 19, 2023 (4 pm - 5:15 pm)July 22 - 26, 2023 (4 pm - 5:15 pm)July 29 - August 2 (4 pm to 5:15 pm)

PAYMENT/CHECKOUT

2024 Summer Sports Training (Weekly Rate)

Paul VI Catholic High School - Chantilly, Virginia

$175.00 Total No. of Weeks
Item subtotal:$0.00

2024 Summer Sports Training - (7 weeks)

$525.00

Total

$0.00

2024 Summer Sports Training Schedule