Athlete Information
First Name:
Last Name:
Student ID #:	Numbers ONLY!
Date of Birth:	mm/dd/yyyy
Contact Phone:	(xxx) xxx-xxxx
Address:
City:
State:	Zip:
Email:
Sex:	Please Select One Male Female
In Case of an Emergency, Please Contact:
First Name:	Last Name:
Contact Phone:	Relationship:   Please select one Mother Father Sister Brother Grandmother Grandfather Legal Guardian Spouse Girlfriend Boyfriend Friend Cousin Aunt Uncle Other
Medical Insurance:
Name of Insurance Company:	Please Select One Kaiser Blue Cross of California Blue Cross Blue Shield Anthem LA Care Cigna HealthNet United Health Care Molina Aetna Medi-Cal Other I do not have health insurance    If Other:
Insurance Policy Number:	Write N/A if you have no insurance.
Allergies to any medications or other medical information emergency personnel should know:
If you have no issues, write NONE.
Please create a password! Passwords must be at least 8 characters long.
Password: