Player Registration

Player Information

Last Name First Name Position Height Grade School Coach Name Coach Phone Birth Date

Age Sex M F Address City State Zip Code Cell Phone Home Phone Email Address Shirt Size Short Size Please attach a JPEG, JPG or PNG of your child's Birth Certificate & Report Card

Parent / Guardian Information

Parent / Guardian's Last Name Parent / Guardian's First Name Email Address Is this player covered by insurance Yes No Name of Primary Insurance Subscriber’s name Birth Date

Group Number Policy Number Player’s relationship to subscriber Other Name of Secondary Insurance (if applicable) Subscriber’s Name Group Number Policy Number Player’s relationship to subscriber Other

In Case of Emergency

Name Relationship to Player Contact Number Name Relationship to Player Contact Number Date

Parent/Guardian signature

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