PersonalParents 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 *Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People’s Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People’s Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweHome Phone *Cell Phone *Work Phone *Email Address *Child's Age *Child's Birth Date *Month/Day/YearChild's Shirt Size *Child's Shorts Size *Child's Sneaker Size *Ethnicity *EthnicityWhiteLatinoBlack/African AmericanAsianWest IndianOtherEmergency Contact Name *RelationshipPhone *EducationWhat is the name of your child's school *Grade Level ? *Upload a copy of your child's school schedule *Choose FileNo file chosenDelete uploaded fileIn 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’sHave you ever been suspended from school for fighting ? *Yes or NoYesNoWhenFor how longHave you ever been suspended from school for Truancy ? *Yes or NoYesNoWhenFor how longHave you ever been suspended from school for other reasons ? *Yes or NoYesNoWhenFor how longHave you ever been expelled discharged from school for fighting ? *Yes or NoYesNoWhenFor how longHave you ever been expelled discharged from school for Truancy ? *Yes or NoYesNoWhenFor how longHave you ever been expelled discharged from school for other reasons ? *Yes or NoYesNoWhenFor how longHas your child now or have they ever seen a school counselorYes or NoYesNoAre they still seeing them ?Yes or NoYesNoIf yes, please explain?0 / 2000Counselor.NameOffice Phone #Have your child ever been held back a grade?Yes or NoYesNoIf yes, which grade ?If yes, what were the reasons0 / 2000On average, how many days a week does your child attend schoolOn average, how many days a week is your child late to schoolEmotional & Physical DevelopmentWhat does your child like to do in his/her free time (hobbies, etc)AccomplishmentsIn 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 / 2000Which of these goals is your child currently working on? Briefly explain how. *0 / 2000Now, 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 / 2000Personal StatementWhy do you want your child to participate in the Rucker Ambassador Elite Basketball Clinic Program? *0 / 2000ProgramWhat would prevent your child from coming to the program and accomplishing his/her goals? *0 / 2000What will be hard for your child in this program – Select all that applyFollowing instructionsBeing honestNot Losing controlCompleting the programTrusting othersNot doing drugsNot fightingStaying awakeMissing classesBeing away from friendsControlling their temperParticipating in physical activitiesLack of confidenceNot smokingNot communicatingPlayer agrees to work on above goals and objectives in order to participate in the RA Elite Basketball ProgramPlayer Signature *Start signing your signature hereYour browser does not support e-Signature field.Parent Signature *Start signing your signature hereYour browser does not support e-Signature field.Rucker Staff Signature *Start signing your signature hereYour browser does not support e-Signature field.Credit / Debit Card *There is a $50 fee to register for the Workout ProgramSend Message