Eureka Junior League Football and Cheer - (Eureka, CA)

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PLAYER INFORMATION

Returning Player

* First Name:

New Player

Football Player

Cheerleader

* Last Name:

* Primary Address (2 utility bill verfications required):

City:

* State:

Zip Code:

Home Phone:

* Birthdate:

* Age as of August 31st:

Email:

Gender:

* School Fall, 2025:

* Grade Fall, 2025:

PARENT/GUARDIAN #1

Firstname:

* Lastname:

* Address:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

* Address:

Email:

Home Phone:

Work Phone:

Cell Phone:

Emergency Contact:

Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Relationship to Player:

Doctor:

Doctor's Phone Number::

Insurance Carrier:

Policy #:

NO REFUNDS

I/we agree with the above *

* indicates required fields