Jr Scots Football Registration 2021
Players First Name: *
Players Last Name: *
Players Mailing Address: *
Email Address: *
Grade in Fall: *
School in Fall:
Weight:
Height:
Date of Birth: *
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Preferred Nickname:
Parent/Guardian # 1 First & Last name: *
Parent/Guardian # 1 Relationship to player: *
Parent/Guardian # 1 Cell/Work Phone number: *
Parent/Guardian # 2 First & Last name:
Parent/Guardian # 2 Relationship to player:
Parent/Guardian # 2 Cell/Work Phone number:
Primary Emergency Contact Name: *
Primary Emergency Contact Relationship: *
Primary Emergency Contact Phone Number: *
Medical Coverage Policy Number: *
Medical Insurance Company and Agent: *
Emergency Contact Physician Name: *
Emergency Contact Physician Phone Number: *
Medical Conditions /Allergies / Medications being taken: *
Electronic Signature of Parent/Guardian *
Date: *
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