Scotia Renegades & Angels

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2023 Fall Ball Registration

Player Information

* Player's First Name:

* Player's Last Name:

* Date of Birth:

* Street:

* City:

* State:

* Zip:

* Desired Number for Uniform:

Positions Played:

* Resident School District:

* T Shirt Size:

AXL

Parent/Contact Information

* Parent or Guardian's Name:

* Home Phone:

Other Phone:

* Email Address:

I certify that the child named above lives at the specified address. *

Comments:

Medical Release Information (Please complete all fields, enter N/A as appropriate)

* Emergency Contact (Other than Parent):

* Emergency Contact Phone:

* Father/Mother Names:

* Father/Mother Phones:

* Father/Mother Cell Phones:

* Family Physician:

* Family Physician Phone:

Orthodontist Name:

Orthodontist Phone:

* Medical Insurance Coverage:

* Allergies or Special Conditions:

In case of an emergency, if our family physician or orthodontist cannot be
reached, I hereby authorize my child to be treated by another qualified, licensed, physician or orthodontist who is available.

I allow emergency treatment as stated above

Parent's name for acknowledgement above:

* indicates required fields

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2023 Fall Ball Registration