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* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

* SCHOOL YOU PLAY FOR:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

*** Insert your waiver information here ***

I/we agree with the above *

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