Fall Registration 2017
Email address
Player First Name
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Player Last Name
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Grade (At time of participation in sport)
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Attending School
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DOB (mm/dd/yyyy)
MM
/
DD
/
YYYY
Sport
Parent/Guardian Name
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Street Address
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City
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State
Home Phone Number
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Cell Phone Number
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Email #1
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Email #2
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Do you have medical insurance?
Subscriber Name:
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Insurance Co.
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Group / Member Id
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Primary Physician Name
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Primary Physician Phone
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Illnessess
If yes, please complete
Your answer
Child on Medication
If yes, please complete
Your answer
Additional Comments
Your answer
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