Registration

Student Information

First Name *

Last Name

Date Of Birth

Grade *Select Grade67891011

Select *Sport(s) Registering ForSoccerFlag FootballGolf

Allergies

Parent/Guardian Information

Name *

Email Address *

Phone *

Street Address

Emergency Contact

Emergency Contact Name *

Relationship *

Emergency Phone

Medical Information

Medical Conditions *

Current Medications *

Insurance Provider *

Policy Number

I authorize emergency medical treatment if necessary.

Waivers & Agreements

I agree to the Liability Waiver.I agree to the Code of Conduct.I consent to media/photo release.

Parent Full Name *

Submit