Players Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 Phone # *

(###)

###

####

Parent 2 Phone # *

(###)

###

####

Emergency Contact Phone # *

(###)

###

####

Do you have a doctor’s permit to participate in physical activities? *

Yes

No

Emergency Authorization Release giving OvaLookD Select staff authority to transport and secure proper medical treatment for the child, In the event as the parent I am not present. *

Agree

Disagree