SNAP SPORTS ATHLETE REGISTRATION DETAIL
New or Returning
Returning
— ATHLETE —
Last
First
Middle
Preferred
Miranda
Eithan
Tomriano
Gender
DOB
Race
Specific Origin Group
Male
November 21, 2008
[35]
[36]
Language(s) spoken
Other
English
Address
24150 Newhall Ranch Road, Apt 6305
City
State
Zip
Valencia
CA
91355
Phone
Email
6612890966
heidi@mailershaven.com
Sports activities
Ice Hockey, Adaptive/Developmental Ice Skating, Flag Football, possibly running.
Athlete Employer
Student
Does the athlete have the capacity to consent to medical treatment on his or her own behalf?
No
— PARENT / GUARDIAN / CONSERVATOR INFORMATION—
Name
Relationship
Heidi Jeffrey
Mother
Street Address
24150 Newhall Ranch Road, Apt 6305
City
State
Zip
Valencia
CA
91355
Email
Phone
heidi@mailershaven.com
6612890966
— EMERGENCY CONTACT INFORMATION —
Name
Relationship
Tom or Mary Jeffrey
Grandparents
Phone
Alternate Phone
Email
6617242220
6614351215
tjeffrey4@hotmail.com
— PHYSICIAN & INSURANCE INFORMATION —
Physician Name
Physician Phone
Dr. Lerner
888-778-5000
Insurance Company
Policy Number
Group Number
Kaiser
0019234758
0019234758
— ATHLETE RELEASE FORM —
Athlete Name
Athlete Signature
Eithan Mirands
Parent/Guardian/Conservator Name
Parent/Guardian/Conservator Signature
Date
Heidi Jeffrey
November 17, 2020
— ATHLETE LIKENESS RELEASE FORM —
Athlete Name
Athlete Signature
Ethan Miranda
Parent/Guardian/Conservator Name
Parent/Guardian/Conservator Signature
Date
Heidi Jeffrey
November 17, 2020
— ATHLETIC WAIVER, RELEASE OF LIABILITY AND SNAP SPORTS – CORONAVIRUS/COVID-19 LIABILITY WAIVER —
Athlete Name
Athlete Signature
Eithan Miranda
Parent/Guardian/Conservator Name
Parent/Guardian/Conservator Signature
Date
Heidi Jeffrey
November 17, 2020
— CORONAVIRUS/COVID-19 FIELD RESERVATION LIABILITY WAIVER —
Athlete Name
Athlete Signature
Eithan Miranda
Parent/Guardian/Conservator Name
Parent/Guardian/Conservator Signature
Date
Heidi Jeffrey
November 17, 2020
I AGREE TO THE SNAP SPORTS TEAM TRAVEL POLICY
I AGREE TO THE SNAP SPORTS MEMBERSHIP POLICY
I AGREE WITH THE SNAP SPORTS SEXUAL ABUSE AWARENESS POLICY
I AGREE TO THE SNAP SPORTS DISCIPLINARY POLICY & PROCEDURES
I AGREE TO THE SNAP SPORTS CONCUSSION AWARENESS AND SAFETY RECOGNITION POLICY & PROCEDURES
