East Los Angeles College Athlete Info
Email address *
First Name *
What is your legal first name?
Your answer
Last Name *
What is your legal last name?
Your answer
What is your student identification number?
Your answer
Sport *
Please indicate the sport you will be playing.
Gender *
Level *
Please indicate your athletic level, not your academic level.
What is your date of birth? *
How old are you? *
Your answer
Phone *
What is your current contact number? (XXX) XXX-XXXX
Your answer
Street Address *
Please indicate your current street address. Please include the street number and street name.
Your answer
City *
Please indicate the current city in which you live.
Your answer
State *
Please indicate the current state in which you live.
Your answer
Zip Code *
Please indicate the zip code of the city in which you live.
Your answer
Emergency Contact *
Please give the first and last name of a responsible individual (preferably a relative) who can be contacted in case of an emergency.
Your answer
Emergency Contact Phone *
Please indicate a valid phone number to contact this person in case of an emergency. (XXX) XXX-XXXX
Your answer
Relationship *
What relationship is the emergency contact?
Medical and Dental Insurance *
Do you have medical and/or dental insurance
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