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COACH INFORMATION

TEAM SELECTION (ie City MASCOT):

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Phone number:

* Email:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Medical Condition(s) that could warrant an Emergency:

* Emergency Contact:

* Emergency Contact Phone:

* Relationship to Coach:

I attest that the above information is correct. *

* indicates required fields

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