Participant's Name: ,
Home Phone:
Address: 
City/Zip: ,
Birth date:           

Age (as of 8/1/07): 

Male          Female
Mother's Information: Father's Information
Name:    Name:
Phone: Phone:
Occupation:    Occupation:
Email: Email:
Emergency Contact: Emergency Contact Phone:
Health Insurance Company: Health Plan/Carrier #:

  Check if no insurance

Father's SSN:       
(needed only if you have no insurance)

Medical Release:  (please check appropriate choice)

      In my absence I give WCYF Coaches and/or Board Members permission to provide or authorize emergency medical services where deemed necessary for my child.

      I do not permit anyone to provide or authorize medical services for my child.  I assume full liability for my child's medical care.

List any medications and/or medical conditions associated with the above child:

School:
Number of Years with WCYF:
Number of Years with other league:
Name of other league:
  

 


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