Player First Name

Player Last Name

Player Date of birth

Gender

Uniform Size
---- Select One ---- Youth Small SmallYouth;Medium MediumYouth Large Adult Small Adult Medium Adult Large Adult Extra Large

Age Group
---- Select One ---- U11 and under (birth years 2009, 2010, 2011, 2012) U14 (birth years 2006, 2007, 2008)

Is there any information you would like us to know about the person you are registering (allergies, traumatic brain injury or jolt to the head)?

Has the player ever recievid medical attention for traumatic brain injury?

Check any symptoms this player has experienced after jolt/bump to the head or body
 Headache or Pressure in Head
 Nausea or Vomiting
 Balance Problems or Dizziness
 Blurry or Double Vision
 Sensitivity to Light or Noise
 Feeling Sluggish or Foggy
 Confusion or Concentration/Memory Problems
 Feeling Down or Just Not Right

Parent / Guardian First Name

Parent / Guardian Last Name

Parent / Guardian Email

Parent / Guardian Phone Number 1

Parent / Guardian Phone Number 2

Street Address

City

State / Province
---- Select One ---- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MU NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AB BC MB NB NL NT NU ON PE QC SK YT PR OTHER

Postal Code

In case we can’t reach the parents/guardians, would you like to let the information of someone else?

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone Number

Emergency Contact Relationship to Participant

Insurance Company Name

Insurance Policy Number

Physician’s Name

Physician’s Adress

Physician’s Phone Number

I Accept the Terms and Conditions Type your name below to confirme & express your agreement