| First Name: * |
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| Last Name: * |
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| Gender: * |
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Birthdate: *
| (Age must be between 9 and 10 as of
8/1/2005.) | |
/ / mm/dd/yyyy |
Email: * |
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| Enter Email Again: * |
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| Home Phone: |
ext.
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| Address Line 1: * |
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| Address Line 2: |
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| City: * |
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| State: * |
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| Country: * |
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| Zip: * |
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Tell your friends and family about this
activity!
| |
(List email addresses separated by
commas) |
| Did your child play in our
league last year? * |
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| Parent
Information |
| Parent #1 First Name * |
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| Parent #1 Last Name * |
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| Parent #1 Address1 * |
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| Parent #1 Address2 |
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| Parent #1 City * |
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| Parent #1 State * |
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| Parent #1 Zip * |
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Parent #1 Phone * (269-555-1212) |
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Parent #1 Work Phone (269-555-1212) |
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| Parent #1 Email * |
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| Parent #1 Relationship * |
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| Parent #1 Occupation |
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| Parent # 1: Which role or
committee would you like to volunteer for? * |
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| Parent #2 First Name |
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| Parent #2 Last Name |
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Parent #2 Work Phone (269-555-1212) |
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| Parent #2 Email |
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| Parent #2 Occupation |
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| Parent #2: Which role or
committee would you like to volunteer for? |
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| Emergency Contact
Information |
| Emergency Contact * |
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Emergency Contact Relationship
* (Example:
Grandparent, Aunt, Uncle, etc.) |
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Emergency Contact Phone * (269-555-1212) |
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Medical Comments (Allergies,
Medical Condition, Medical Concerns, etc.)
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