LAKEWOOD SOCCER CLUB

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PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

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PARENT/GUARDIAN #1

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Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

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Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

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I/we agree with the above *

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