Stockton Jr Jackets

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DYFL Registration Form

Date Completed

Franchise / Team Name *

Player DivisionJr. NoviceNoviceJr. VarsityVarsityVeteranMascot/WaterpersonJr. Varsity Older-LighterNovice Older-Lighter

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Franchise

Players First Name *

MI

Players Last Name *

Date Of Birth *

Age (as of 31 July)

Current Grade (Sept.)

Street Address *

Apartment, suite, etc

City

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ZIP / Postal Code

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Phone *

Email Address *

Confirm Email Address *

High School District (of attendance)

School Attending (of Sept.)

Is your child currently taking any medication? *YesNo

What medication?

Does your child have any known allergies? *YesNo

What allergies?

Does your child have any type of pre-existing heart or other medical condition? *YesNo

What pre-existing heart or other medical condition?

In case of an emergency, who do we notify? *

Emergency Contacts Name *

Emergency Phone *

Parent's Signature *

Player's Signature *

Payment Amount *

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Initials

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StocktonJrJackets

StocktonJrJackets, Stockton, CA

Est. 2016

(209) 684-6505

contact@StocktonJrJackets.com

Stockton Jr Jackets

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