Eureka Youth Basketball
Player Name
Grade :
Gender
Parent or Legal Guardian Name:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Home phone #
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Name of person in case of an emergency: (secondary to parent/guardian)
Phone number of person in case of an emergency:
Medication taken:
List all known allergies:
Activity restrictions:
Date
-
Month
-
Day
Year
Date
Signature of Parent or Legal Guardian
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Should be Empty: