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Personal

Parents Name *

Child's Legal Name (Last) *

(First) *

Child's Nick Name (what you want to be called) *

Home address (Street) *

Apt #:

City *

State *

ZIP / Postal Code *

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Home Phone *

Cell Phone *

Work Phone *

Email Address *

Child's Age *

Child's Birth Date *

Month/Day/Year

Child's Shirt Size *

Child's Shorts Size *

Child's Sneaker Size *

Ethnicity *EthnicityWhiteLatinoBlack/African AmericanAsianWest IndianOther

Emergency Contact Name *

Relationship

Phone *

Education

What is the name of your child's school *

Grade Level ? *

Upload a copy of your child's school schedule *

No file chosen

In the past school year, what grades did your child receive?Mostly A'sA's and B'sMostly B'sB's and C'sMostly CsC's and D'sMostly DsD's and F'sMostly F's

Have you ever been suspended from school for fighting ? *Yes or NoYesNo

When

For how long

Have you ever been suspended from school for Truancy ? *Yes or NoYesNo

When

For how long

Have you ever been suspended from school for other reasons ? *Yes or NoYesNo

When

For how long

Have you ever been expelled discharged from school for fighting ? *Yes or NoYesNo

When

For how long

Have you ever been expelled discharged from school for Truancy ? *Yes or NoYesNo

When

For how long

Have you ever been expelled discharged from school for other reasons ? *Yes or NoYesNo

When

For how long

Has your child now or have they ever seen a school counselorYes or NoYesNo

Are they still seeing them ?Yes or NoYesNo

If yes, please explain?0 / 2000

Counselor.Name

Office Phone #

Have your child ever been held back a grade?Yes or NoYesNo

If yes, which grade ?

If yes, what were the reasons0 / 2000

On average, how many days a week does your child attend school

On average, how many days a week is your child late to school

Emotional & Physical Development

What does your child like to do in his/her free time (hobbies, etc)

Accomplishments

In order to benefit fully from their participation in the program, we ask that you take a moment to state specifically what you intend for your child to accomplish by participating in the program. These could be related to school, work, family, friends and relationships By next year he/she wants to accomplish : Please write below *0 / 2000

Which of these goals is your child currently working on? Briefly explain how. *0 / 2000

Now, Think about the things that you want your child to avoid repeating in the upcoming year. Next year he/she wants to avoid repeating the following: *0 / 2000

Personal Statement

Why do you want your child to participate in the Rucker Ambassador Elite Basketball Clinic Program? *0 / 2000

Program

What would prevent your child from coming to the program and accomplishing his/her goals? *0 / 2000

What will be hard for your child in this program – Select all that apply

Following instructionsBeing honestNot Losing controlCompleting the programTrusting othersNot doing drugsNot fightingStaying awakeMissing classesBeing away from friendsControlling their temperParticipating in physical activitiesLack of confidenceNot smokingNot communicating

Player agrees to work on above goals and objectives in order to participate in the RA Elite Basketball Program

Player Signature *

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Parent Signature *

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Rucker Staff Signature *

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Credit / Debit Card *

There is a $50 fee to register for the Workout Program