Harlem Lacrosse—LA Registration

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

Participant

Name

First Name

Last Name

Birthdate

YYYY

Gender

Primary Language

Participant Email Address

Participant Phone Number

(###)

###

####

Ethnicity

African American, Black, Caribbean American

Hispanic or Latino/a

Native American

Asian or Pacific Islander

White/Caucasian

Bi-Racial

Multi-Racial

Other

School

If "other school," please specify which school here:

Current Grade (2018-19)

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone Number

(###)

###

####

Cell Phone Number

(###)

###

####

Do you qualify for a 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

LATim JenkinsAugust 28, 2017

Harlem Lacrosse—LA Registration

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

LEAD SUPPORTER

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