STOMP Basketball Contact Form
Please fill out your details and parental consent to register. This the form of interest and to be able to join workouts, is not the form to officially sign on for team activity such as game participation.
Participant's Full Name
*
First Name
Last Name
Participant's Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
School
*
Grade
*
Please Select
6th
7th
8th
9th
10th
11th
12th
Other
Position(s)
*
PG/SG/F/C
Instagram:
@
I Could Be Better At (Check all that apply)
Shooting
Passing
Handles
Defense
Rebounding
Athleticism
Strongest Skill (Check all that apply)
Shooting
Passing
Handles
Defense
Rebounding
Athleticism
Recent injuries (if any in the past 2 years)
Medical Conditions (if any)
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Relationship
*
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Liability Release - During this season, every effort will be made to ensure player safety, however with any exercise program, game, and practice session there are risks including but not limited to muscular injury, skeletal injury, and heart stress. With the request for this program, the parent agrees to assume responsibility for any and all damage to the player, as well as release any and all liability from R Personal Fitness. By signing below, the parent has disclosed any and all prior injuries and medical conditions, accepts full responsibility for player health, well being, and possible injury. No responsibility falls on Regis Pagett, or R Personal Fitness LLC.
*
Please Print name of signee:
*
Register
Register
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