Harlem Lacrosse—Philadelphia 2017 Fall Season If you are a student at a Harlem Lacrosse—Philadelphia school, please sign up to play here: Participant Name * First Name Last Name Birthdate * MM DD YYYY Gender Male Female Primary Language English Spanish 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) Thomas K. Finletter School B. Anderson School 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? Yes No Prefer not to answer Highest grade in school completed by participant's parent/guardian Less than high school Graduated high school or obtained GED Some college but did not graduate College graduate Graduate degree Prefer not to answer 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 (###) ### #### Email Relationship to Participant Emergency Contact Name First Name Last Name Email Cell Phone Number * (###) ### #### Secondary Phone Number (###) ### #### Relationship to Participant Thank you! PhiladelphiaHarlem LacrosseSeptember 6, 2017 Facebook0 Twitter LinkedIn0 Reddit Tumblr Pinterest0 0 Likes
