Player's Name   Age Grade
School
Parent's Name       
 Mailing Address 

Phone     Email (needed for confirmation)
Emergency number (if different from Phone number above)

(No accident insurance provided - parents are responsible for any medical care needed.)

Subscriber's Name   Employed by

Medical insurance provider   Policy #
Group # I.D.#
Special Medical Needs or instructions

____________________________________(Signature here if you print this form to submit.)

Initials here to authorize online

Comments

 Cost $85- Payment is due first day.                        You can use secure PayPal online for payment. or mail to PO Box 1592 Pt Orchard, WA 98366