Volleyball Madness Late Registration

* Student First Name

* Student Last Name

* Address

* City

* State

* Zip Code

* Student Phone

* Email to send registration confirmation

Student Email

* Birthdate

* Grade entering in the fall

How did you hear about Volleyball Madness? (select all that apply)

* Is this your first year at Volleyball Madness?

Teammate/Coach Preference (No guarantees. First-time players only.)

* Have you played volleyball before?

If yes, what league/school?

* Shirt Size

Parent/Guardian Info

* Parent/Guardian Email

* Parent/Guardian Mobile Phone

Emergency Contact

* First Name

* Last Name

* Phone Number

Medical Information

* Does your child have any health concerns or physical limitations that we need to know about?

If yes, please explain

* Date of Last Tetanus Shot

If your child should require medical attention for injuries received or illness contracted prior to this activity, give instructions here.

* Do you have Health Insurance?

* Insurance Company

* Insurance Company Address

* Policy Number

Medical Release

In the event that I cannot be reached in an emergency during this activity/league, I hereby give my permission to the physician or dentist selected by Valley Bible Church to hospitalize, to secure proper treatment, and/or an injection, anesthesia, or surgery for my child as deemed necessary. (Select yes below to agree.)

* I agree and give my permission

Payment Selection

* Registration Fee

Total Price:

$0.00

Billing Address

* Country

* Address

* City

* State

* Zip Code

Payment Information

* Credit Card Type

* Name on Credit Card

* Credit Card Number

* Expiration Date

* CCV Code

click here for help

CLICK THE SUBMIT BUTTON ONLY ONCE! Clicking twice may charge your card a second time.

By attending/participating in this activity/league, I understand that we will be participating in activities and may also be receiving food, beverages, and/or candy at this event. I also understand that photos or video may be taken and used by Valley Bible Church for promotional purposes only, and will not be sold to other parties. While measures are taken to ensure safety, as with any activity or event, there is a risk of sickness or injury. I fully accept this risk and hold harmless from any legal liability, Valley Bible Church and any staff, volunteers, or representatives involved in this activity/league.