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Carolina Express Player Registration

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

* Birthdate:

Email:

* Gender:

* Grade:

PARENT/GUARDIAN #1

Firstname:

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:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

Please list Team and Coach Name

* :

I/we agree with the above *

Signature:

Date:

* indicates required fields

IMPORTANT: Online Payment with credit cards is not active for this form

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