Section 1 of 4 in this document
2021 Justin Wilcox Skills Camp Registration 6/27/2021
Participant Contact Information
Participant Name
First Name
*
Initial
Last Name
*
Date Of Birth
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Participant Phone Number
Full Address
Street Address
City
State
Zip
High School
Grade in Sept. 2021
Junior
Senior
HS Grad Year
2022
2023
High School Film Link (Hudl, Youtube)
Participant Type
Position(s)
QB
WR
RB
TE
DB
LB
Section 2 of 4 in this document
Parent/Contact
First Name
*
Last Name
*
Parent/Contact Phone Number
*
Parent/Contact Email
*
Emergency/Medical Information
Alternate Emergency Contact (Different from Parent/Contact)
First Name
*
Last Name
*
Phone Number
*
Doctor Information
First Name
*
Last Name
*
Phone Number
*
Medical Insurance Company
*
Policy #
*
Policy Exp. Date
Month
*
MM
January
February
March
April
May
June
July
August
September
October
November
December
Day
*
DD
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
*
YYYY
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Policy Holder Name
First Name
*
Initial
Last Name
*
Medications
Yes
No
List Medications (including inhalers)
Please list any other health information relevant to camp participation
2020 Skills Camp 6/21/2020
Skills Camp 6/21/2020
50.00
Subtotal
Payments processed through Stripe.
Card Holder Name
Credit Card Number
Security Code
Expiration
Month
January (01)
February (02)
March (03)
April (04)
May (05)
June (06)
July (07)
August (08)
September (09)
October (10)
November (11)
December (12)
Date
Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
Section 3 of 4 in this document
disregard this