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THE ROCK ATHLETICS
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Referral Information
How did you hear about us?
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Email
Newspaper Ad
Personal Referral
School Programs
THE ROCK Website
Transfer
Walk In
Referral Name
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Family Information
Family Last Name
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Where do you live?
Home Address
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City
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State
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AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
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NY
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OH
OK
OR
PA
RI
SC
SD
TN
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UT
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WI
WV
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VI
Zip
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Primary Phone
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Additional Info
Emergency Contact Info (Not Contact #1 or #2)
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Contact #1
Contact #1 First Name
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Last Name
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Type
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Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
How Can We Contact You?
Home Phone
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Work #
Cell #
Portal Access (your email is your login)
Email
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(Emails are kept confidential)
Confirm Email
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Portal Account Password
Confirm Portal Account Password
Contact #2
Contact #2 First Name
Last Name
Type
Father
Grandparent
Guardian
Mother
Other
Parent
Step Father
Step Mother
How can we contact you?
Home Phone
Work #
Cell #
Email
(Emails are kept confidential)
Confirm Email
Who is your employer?
Employer
Employer Phone
Employer Notes
Student #1
Student's First Name
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Last Name
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Student Gender
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Female
Male
Birth Date
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Cell #
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Additional Info
Student Email
School
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Grade Level
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preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
picture of athlete
Student #2
(Show-Hide Details)
Student's First Name
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Last Name
*
Student Gender
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Female
Male
Birth Date
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Cell #
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Additional Info
Student Email
School
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Grade Level
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preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
picture of athlete
Student #3
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
*
Additional Info
Student Email
School
*
Grade Level
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
picture of athlete
Student #4
(Show-Hide Details)
Student's First Name
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Last Name
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Student Gender
*
Female
Male
Birth Date
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Cell #
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Additional Info
Student Email
School
*
Grade Level
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
picture of athlete
Student #5
(Show-Hide Details)
Student's First Name
*
Last Name
*
Student Gender
*
Female
Male
Birth Date
*
Cell #
*
Additional Info
Student Email
School
*
Grade Level
*
preschool
kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
college
college-freshman
college-sophomore
college-junior
college-senior
Unknown value
Disabilities (Leave blank if NONE)
Special Needs (Leave blank if NONE)
Allergies (Leave blank if NONE)
Medications (Leave blank if NONE)
picture of athlete
Add Another Student
Required Policies
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I Agree to All of the Above
Enter your Full Name
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December 26, 2024
Questions or Concerns
Comments
Payment Information
Account Information
Membership Type
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All-star
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Card Nickname
Name as it appears on card
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Address Line 1
Address Line 2
City
State
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AZ
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DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
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WA
WI
WV
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PR
VI
Zip
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eCheck/Bank Draft
Bank Name
Account Type
Checking
Savings
Your Account Name
(Your name on your bank statement)
Bank Routing Number
(9-digit number)
Account Number