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WIA Express Player Information Form
One per player
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* Indicates required question
Player Name
*
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Height (HS only)
Your answer
Weight (HS only)
Your answer
School
*
Your answer
Fall 2020 Grade
*
Your answer
Parent Primary Contact Information
Name
*
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
*
Your answer
Email Address
*
Your answer
Alternate Contact Person
Name
*
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone
*
Your answer
Email Address
*
Your answer
Additional Information
Medical Conditions
*
Your answer
Eye Glasses or Contact
*
Eye Glasses
Contacts
Both
Neither
To the best of my knowledge I am able to play basketball with the associated conditioning at a high level of physical exertion.
By typing my name below, I acknowledge the above statement as a PLAYER.
*
Your answer
By typing my name below, I acknowledge the above statement as the PARENT of the player.
*
Your answer
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