Step 1 of 333%Player Info* Please note that the information you provide will also be shared with our athletic therapists *Name* First Last Address* Street Address App. City State / Province / Region ZIP / Postal Code Email* Phone*Birthdate* Medicare card*New Player*YesNoFor new players, how did you hear about us? If referral, who referred you?Level 2020*Tykes (DOB: 2013-2015) $130.00 CADAtom (DOB: 2011-2012) $200.00 CADMosquito (DOB: 2009-2010) $200.00 CADPeewee (DOB: 2007-2008) $200.00 CADMidget (DOB: 2003-2004) $300.00 CADBantam (DOB: 2005-2006) $300.00 CADJunior (DOB: 1996-2002) $350.00 CADCheerleaders $130.00 CADEMERGENCY CONTACTName* First Last Relationship*Phone*Email* ALTERNATE EMERGENCY CONTACTName* First Last Relationship*Phone*Email* PLAYER MEDICAL INFORMATIONPlease list all known allergies, including to tape and/or glue:*In the case of allergies, do you have an Epi-Pen?*YesNoPlease list all medications, including for asthma:*Do you wear glasses?*YesNoDo you wear contact lenses?*YesNoDo you have hearing problems?*YesNoDo you have epilepsy?*YesNoDo you have any learning disabilities or concentration problems (dyslexia, ADD, ADHD,etc)?*YesNoDo you have asthma?*YesNoDo you have diabetes?*YesNoDo you suffer from cardiac or vascular problems?*YesNoDo you have high blood pressure?*YesNoDo you suffer from frequent fainting spells?*YesNoPlease identify the number of previous concussions*012345+In the case of previous concussion(s), when was the last one?*In the case of previous concussion(s), in relation to the most recent one, how long did the symptoms last?*Please list any surgeries you have undergone*Please list all injuries suffered in the past 2 years that required you to sit out of play for more than 1 week*If you suffer from any other condition or disease, not listed above, please specify*CommentsPaymentPayment Method*Credit/Debit Card (Online)Cheque (in person)Cash (in person)E-transfer Interac (email to vpadmin@gpkpackers.com)Total Amount $ 0.00 CAD Credit Card*MasterCardVisa Card Number Expiration Month/Year Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Security Code Cardholder Name Email used for Interac eTransfer:* Note: Please include the player’s name in the message field when sending the Interac eTransfer.Jumpstart confirmation # (if applicable) I confirm that I am 14 years or older* I consent to medical information being shared with medical partners, when necessary for the management of injury/health condition* I acknowledge the policies and my signature below indicates my consentBy signing below, you are authorizing the GREENFIELD PARK PACKERS Football Association to use photographs and/or video of you for the sole purpose of official GREENFIELD PARK PACKERS business (web site, newsletters, registration flyers, etc.). All photographs and/or video footage may only be taken during official GREENFIELD PARK PACKERS functions (practice, games, registration, etc.). ALSO, YOU ARE CONFIRMING THAT THE SUPPLIED INFORMATION IS CORRECT AND YOU UNDERSTAND THAT, SHOULD YOU BE UNABLE TO ANSWER QUESTIONS PERTAINING TO YOUR HEALTH, THE FIRST RESPONDER WILL RELY ON THE SUPPLIED INFORMATION TO ASSIST YOU WITH YOUR AILMENT. In such a case your consent to assistance will also be implied.Signature*Use you mouse to create your signature or put your initialsName of signee*Payment completedPayment ReceivedPayment Incomplete
