SPAC Registration Form

NOTE:
If you plan to register more than one child, please reigseter each child on a separate registration form.

STUDENT INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Grade REQUIRED Please fill out this field.

Date of Birth REQUIRED Please fill out this field. Please enter a date.

Address: REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

SPORT/CLUB SELECTION

Select the sport/club you are interested in: REQUIRED Inner Drive Hoops Basketball Program ($30) | Grades 2-8 Running Club ($30) | Grades 4-8 (Tues/Thurs after school) Tennis Club ($25) | Grades 1-8 (Sun 12pm beginning 4/18/21; equipment not provided) Pickleball Club ($25) | Grades 5-8 (Weds after school) Upper School Golf Clinic ($120) | Grades 6-8 (Fri 3pm @ Princeton Country Club on 4/16, 4/23, 4/20, 5/07) Please fill out this field.

PARENT INFORMATION

Email REQUIRED Please fill out this field. Please enter an email address.

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Phone Number (Secondary) Please enter a phone number.

EMERGENCY CONTACT INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

2nd EMERGENCY CONTACT INFORMATION

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

STUDENT MEDICAL INFORMATION

Medical Insurance REQUIRED Please fill out this field.

Have you ever been medical advised NOT to play any sport? REQUIRED Yes No Please fill out this field.

Do you have any concerns about participating in sports? REQUIRED Yes No Please fill out this field.

Do you have a bleeding disorder? REQUIRED Yes No Please fill out this field.

Have any members of your family under age 50 had a heart attack, heart problem, or died unexpectedly? REQUIRED Yes No Please fill out this field.

Have you ever had a seizure, convulsions, been unconscious, or suffered memory loss? REQUIRED Yes No Please fill out this field.

Do you have a history of heart, blood pressure, or chest pain problems? REQUIRED Yes No Please fill out this field.

Have you ever experienced heat stroke or fainting after exercise? REQUIRED Yes No Please fill out this field.

Do you have any vision impairments or wear glasses/contact lenses? REQUIRED Yes No Please fill out this field.

Do you take daily or regular medications? REQUIRED Yes No Please fill out this field.

Are you allergic to anything? REQUIRED Yes No Please fill out this field.

Are you under a doctor's care? REQUIRED Yes No Please fill out this field.

Have you ever had an illness that (check all that apply): REQUIRED Required you to stay in the hospital Lasted longer than a week Caused you to miss three or more days of practice or competition Is chronic (e.g., asthma, diabetes, etc.) None of the above Please fill out this field.

Have you ever had an injury that (check all that apply): REQUIRED Required X-rays Required you to go to the emergency room or see a doctor Required you to stay in the hospital Caused you to miss three or more days of practice or competition None of the above Please fill out this field.

Have you (the student) ever been diagnosed with COVID-19? REQUIRED Yes No Please fill out this field.

If diagnosed with COVID-19, were you symptomatic? REQUIRED Yes No I haven't been diagnosed with COVID-19 Please fill out this field.

If diagnosed with COVID-19, were you hospitalized? REQUIRED Yes No I haven't been diagnosed with COVID-19 Please fill out this field.

ONE LAST QUESTION...

Are you (the parent/guardian) planning to volunteer and assist with any activities? Yes No

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