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PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

City:

State:

Zip Code:

* Home Phone:

* Birthdate:

* Email:

* Gender:

* Grade:

PLAYER 2

Firstname:

Lastname:

EMail:

Birthdate:

Gender:

Grade:

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 GIVES US PERMISSION TO ASSIST IF MEDICAL ATTENTION IS NEEDED

*** Insert your waiver information here ***

I/we agree with the above *

* Parent, Guardian or Adult E-mail:

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