New Youth Registration

First Name

Last Name

Birthdate

School Name

Street

City

State/Province

Zip

Phone

Primary Race/Ethnicity

Secondary Race/Ethnicity:

Gender

Primary Language at Home

Current Grade:

Emergency Contact 1 Name:

Emergency Contact 1 Alt Phone:

Emergency Contact 1 Main Phone:

Emergency Contact 1 Address:

Emergency Contact 2 Name:

Emergency Contact 2 Main Phone:

Emergency Contact 2 Alt Phone:

Emergency Contact 2 Address:

Medical Issues:

Allergies:

Dietary Restrictions:

Doctor Phone Number:

Person who filled out registration form:

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