Participant Child Information
Please fill out the following information for the participating child.

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Si ou bezwen wè fòm sa a nan yon lòt lang, klike sou dwa sou paj la epi chwazi "Tradui nan ..." epi chwazi lang ou ta renmen li a nan.

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Student Name
hereinafter, “Student”
First Name *
Last Name *
Date of Birth *
Gender *
Ethnicity *
BPS ID Number (optional)
Has your child participated in Soccer for Success / Boston Scores before? *
Student's Phone (optional)
Student's Email *
This question is required so coaches can send virtual login information to students.
Student's Primary Language *
Medical Information
Medical Concerns
Primary Care Physician
Physician Phone
Health Insurance Provider
Transportation Plan and Consent
If your child will be picked up by someone not listed on this form you must send a written note to their teacher.
Does your child have permission to walk, bicycle, or take public transportation home on their own? *
My child will get home after the program each day in the following manner:
Not to be picked up by
We intend to play inter-scholastic games in 2021-22 if conditions allow. These questions allow you to consent to which activities which inter-scholastic activities you are comfortable having your child participate in. *
Grade Level for the 2021-2022 school year *
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