ATHLETIC REGISTRATION FORM
Student Information
Student Name
*
First Name
Last Name
Grade
*
Please Select
Kindergarten - Mary Littlepage
Kindergarten - Stephanie Espinoza
1st Grade - Beka Mikesell
1st Grade - Heather Michaud
2nd Grade - Ashley Horton
2nd Grade - Tabitha Tomlinson
3rd Grade - Bethany Miyamoto
3rd Grade - Bekah Kolstad
4th Grade - Lauren Burwell
4th Grade - Tracie Meister
5th Grade - Esther McGuire
5th Grade - Kaylee Osegueda
6th Grade - Tiara Garrett
6th Grade - Anya Zhakevich
Middle School
Date of Birth
*
-
Month
-
Day
Year
Date
Parent / Guardian Information
Parent / Guardian Name
*
First Name
Last Name
Email Address
*
example@example.com
Home Phone Number
*
Work Phone Number
Cell Phone Number
Address
Team Information
Team Sports
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TBA
$
Free
Total
$
0.00
Emergency Contacts
Name
Relationship
Home Phone Number
Work Phone Number
Cell Phone Number
Medical Information
Doctor
Insurance Carrier
Policy No
Allergies
Terms and Conditions
Terms & Conditions
*
By checking this box you authorize Legacy Christian Academy to charge the Activity Fee amount to your FACTS account.I give permission for my child to participate on the sports team. I have read the policies regarding participation, and I understand that participating on an athletic team is a privilege. I also assume the risk of any and all injuries incurred during his/her participation in this “activity” or “sports team” (including transportation to and from the event). I also release Legacy Christian Academy, including all the representatives, leaders and chaperones (both officially and personally), from any liability from which the release might exist. In the event that our child becomes ill or sustains and injury while in the care or under the supervision of Legacy Christian Academy, I hereby authorize any staff member or leader to administer first aid treatment for his/her relief. If it is not practical to return him/her to any hospital: consent is also given to any licensed physician and or surgeon called or to who our child is taken for treatment by them to administer such treatment, drugs, and medicines, and to perform such surgical procedures as he shall think the existing emergency requires for the relief of pain and the preserve his/her life and health. Authorization is also given for such other measures or procedures as may be required. I hereby agree to reimburse Legacy Christian Academy for any expenses incurred in the case of my child, should any type of medical treatment become necessary. This would include hospitals, doctors, ambulance, etc. Legacy Christian Academy
Authorization Signature
Authorization
*
By signing below, I certify that I am the Parent or Legal Guardian of the student named above and that all the information provided is true and correct to the best of my knowledge.
Parent / Guardian Signature
*
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Legacy Christian Academy
27680 Dickason Drive
Valencia, CA 91355
Phone: 661.257.7377
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