Cheerleading Registration

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RM_Stats
Player Info
Email^*
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type=”email” name=”Email_102″ placeholder=”Email” class=”rm_form_default_fields” required value=”” id=”rm_reg_form_email_7_1″/>
Cheerleader Information

Child First Name^*
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type=”text” name=”Textbox_104″ placeholder=”Child First Name” required field_validation custom_validation value=”” id=”form_7_1-element-8″/>
Child Middle Name
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type=”text” name=”Textbox_105″ placeholder=”Child Middle Name” field_validation custom_validation value=”” id=”form_7_1-element-9″/>
Child Last Name^*
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type=”text” name=”Textbox_106″ placeholder=”Child Last Name” required field_validation custom_validation value=”” id=”form_7_1-element-10″/>
Gender^*
Male

Female

Date of Birth^*
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type=”text” autocomplete=”off” readonly=”1″ name=”jQueryUIDate_108″ placeholder=”Date of Birth” field_time_zone required date_format=”mm/dd/yy” value=”” data-dateformat=”mm/dd/yy” id=”form_7_1-element-12″/>

Grade (in August)^*
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type=”text” name=”Textbox_111″ placeholder=”ex: 4″ required field_validation custom_validation value=”” id=”form_7_1-element-14″/>
Name of School^*
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type=”text” name=”Textbox_112″ placeholder=”Name of School” field_time_zone required value=”” id=”form_7_1-element-15″/>

Medical Information

Medical Concerns
Physician Name^*
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type=”text” name=”Textbox_116″ placeholder=”Physician Name” required field_validation custom_validation value=”” id=”form_7_1-element-19″/>
Physician’s Phone Number^*
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type=”text” name=”Phone_117″ placeholder=”Physician's Phone Number” required field_validation custom_validation value=”” pattern=”^(\d[\s-]?)?[$\[\s-]{0,2}?\d{3}[$\]\s-]{0,2}?\d{3}[\s-]?\d{4}$” id=”form_7_1-element-20″/>
Hospital of Choice^*
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type=”text” name=”Textbox_118″ placeholder=”Medical Center” required field_validation custom_validation value=”” id=”form_7_1-element-21″/>
Medical Insurance Company^*
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type=”text” name=”Textbox_119″ placeholder=”Medical Insurance Company” required field_validation custom_validation value=”” id=”form_7_1-element-22″/>
Medical Insurance Policy Number^*
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type=”text” name=”Textbox_120″ placeholder=”Policy Number” required field_validation custom_validation value=”” id=”form_7_1-element-23″/>
Medical Insurance Policy Holder^*
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type=”text” name=”Textbox_121″ placeholder=”Holder's Name” required field_validation custom_validation value=”” id=”form_7_1-element-24″/>
Parent Info
Parent/Guardian 1 Information

Parent First Name
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type=”text” name=”Fname_123″ placeholder=”Parent First Name” field_validation custom_validation value=”” id=”form_7_1-element-31″/>
Parent Last Name^*
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type=”text” name=”Lname_124″ placeholder=”Parent Last Name” required field_validation custom_validation value=”” id=”form_7_1-element-32″/>
Parent Email^*
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type=”text” name=”Nickname_125″ placeholder=”Parent Email” required field_validation custom_validation value=”” id=”form_7_1-element-33″/>
Parent Mobile Number^*
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type=”text” name=”Phone_126″ placeholder=”478-123-4567″ required field_validation custom_validation value=”” pattern=”^(\d[\s-]?)?[$\[\s-]{0,2}?\d{3}[$\]\s-]{0,2}?\d{3}[\s-]?\d{4}$” id=”form_7_1-element-34″/>
Parent/Guardian 2 Information

Parent 2 First Name
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type=”text” name=”Textbox_128″ placeholder=”Parent 2 First Name” field_validation custom_validation value=”” id=”form_7_1-element-36″/>
Parent 2 Last Name
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type=”text” name=”Textbox_129″ placeholder=”Parent 2 Last Name” field_validation custom_validation value=”” id=”form_7_1-element-37″/>
Parent 2 Mobile Number
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type=”text” name=”Phone_130″ placeholder=”478-123-4567″ field_validation custom_validation value=”” pattern=”^(\d[\s-]?)?[$\[\s-]{0,2}?\d{3}[$\]\s-]{0,2}?\d{3}[\s-]?\d{4}$” id=”form_7_1-element-38″/>
Emergency Contact

Emergency Contact Name^*
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type=”text” name=”Textbox_132″ placeholder=”Emergency Contact Name” required field_validation custom_validation value=”” id=”form_7_1-element-40″/>
Emergency Contact Number^*
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type=”text” name=”Phone_133″ placeholder=”478-123-4567″ required field_validation custom_validation value=”” pattern=”^(\d[\s-]?)?[$\[\s-]{0,2}?\d{3}[$\]\s-]{0,2}?\d{3}[\s-]?\d{4}$” id=”form_7_1-element-41″/>
Refunds
Refunds^*
I understand that NO REFUNDS will be given unless the program does not have enough participants.
I Agree