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GG PB Academy

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Intake Form


GG Pickleball Intake Form
1

Form Results
1
Full Name of Parent/Guardian
Notes
Status
Relationship to Student
Email Address
Phone Number
Mailing Address
Full Name (Student)
DOB (Student)
Gender
Grade
PB Experience
PB Experience Desc
Program Preferences
Column 13
Would you like information on our referral program?
Emergency Contact (1. Full Name: 2. Relationship to Student: 3. Phone Number:)
Medical Information: 1. Does the student have any allergies or medical conditions we should be aware of? (Yes/No) 2. If yes, please provide details:
How did you hear about GGPB?
Goals/Focus Areas
If Yes (Medical)
Column 20
1
Steven Neely
Inquiry
Father
615-403-7729
Open
Knox Neely
01/16/2015
Male
8
Yes
Very, very casual play. Not much experience at all.
Group
Saturday, after 10am or weekday evenings, after 5:30pm
Yes
Ashley Neely, Mother, 615-752-7106
No
Friend/Neighbor
Learn the basics of the game such as rules.
2
Nate Lyden
Inquiry
Parent
410-350-1136
Open
Bode Lyden
09/12/2014
Male
8
Yes
Casual play (has played tennis for a few years)
Fri/Sat/Sun
Nate Lyden
No
Friend/Neighbor
3
Chris Picciurro
Inquiry
Father
5867137753
Open
Christian Picciurro
01/09/2009
Male
13+
Yes
Played 8 times with family
Both
Tuesday to Friday
Yes
Holly Picciurro Mother 5864194360
No
Friend/Neighbor
4
Chris Picciurro
Inquiry
Father
5867137753
Open
Luke Picciurro
04/16/2013
Male
10
Yes
Played 8 times with family
Both
Tuesday or Thursday
Yes
Holly Picciurro Mother 5864194360
No
Friend/Neighbor
5
David Barnett
Inquiry
Father
6157449234
Open
Rhys Barnett
09/03/2010
Male
12
Yes
Light, fun play with me and friends
Group
Weekend Or anytime during summer
Yes
Nicole Barnett, mom, 6157459919
Yes
Facebook
Basic skills & rules
Nut allergy: peanuts , pistachios, cashews
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