Chicago House AC-1

Chicago House AC Women's U23 Team Registration Form

Player First Name *

Player Last Name*

Date of birth*

Player Primary Phone Number*

Player Primary Email Address*

Street address*

City*

State/Region*

Parent First name*

Parent Last name*

Primary Parent Email*

Primary Parent Primary Phone number*

Parent 2 First Name

Parent 2 Last Name

Parent 2 Email Address

Parent 2 Primary Phone Number

Emergency Contact Full Name*

Emergency Contact Phone Number*

Emergency Contact Relationship to Player*

List any Allergies (or n/a)*

Other Medical Conditions

Physician Name*

Medical/Insurance Company*

Medical/Insurance Phone Number*

Policy Holders Name*

Policy Number*

Upload Player Headshot*