Harlem Lacrosse—Boston 2017 Fall Season

If you are a student at a Harlem Lacrosse—Boston school, please sign up to play here:

Participant

Name

First Name

Last Name

Birthdate

YYYY

Gender

Primary Language

Email Address

Ethnicity

African American, Black, Caribbean American

Hispanic or Latino/a

Native American

Asian or Pacific Islander

White/Caucasian

Bi-Racial

Multi-Racial

Other

School

(Only students who attend schools listed here are eligible to participate)

Current Grade (2017-18)

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

Do you qualify for federal or state free or reduced lunch program?

Highest grade in school completed by participant's parent/guardian

Medical Information

Allergies

Medications

Additional Medical Concerns

Primary Care Physician

Physician Phone Number

(###)

###

####

Health Insurance Provider

Health Plan Number

Parent/Guardian

Name

First Name

Last Name

Cell Phone Number

(###)

###

####

Secondary Phone Number

(###)

###

####

Relationship to Participant

Emergency Contact

Name

First Name

Last Name

Cell Phone Number

(###)

###

####

Secondary Phone Number

(###)

###

####

Relationship to Participant

BostonHarlem LacrosseAugust 30, 2017

Harlem Lacrosse—Boston 2017 Fall Season

If you are a student at a Harlem Lacrosse—Boston school, please sign up to play here:

LEAD SUPPORTER

© 2018 Harlem Lacrosse. All Rights Reserved. Harlem Lacrosse is a registered 501(c)(3) non-profit organization in the State of New York.