Sporting Southern Indiana Tryout Registration 2015-2016

Player Information

Full Legal Name *
Full Legal Name
Date of Birth *
Date of Birth
Address *
Address
Primary AlPhone *
Primary AlPhone
Alternate Phone
Alternate Phone
(years)
Emergency Contact 1 Phone *
Emergency Contact 1 Phone
Emergency Contact 1 Phone (alternate)
Emergency Contact 1 Phone (alternate)
Emergency Contact 2 Phone
Emergency Contact 2 Phone
Emergency Contact 2 Phone (alternate)
Emergency Contact 2 Phone (alternate)
Physician Phone *
Physician Phone
Enter 'None' if you do not have insurance.
Insurance Provider Phone
Insurance Provider Phone
Please sign below to certify that you are over the age of 13 or are the legal guardian of the above player. *
*Putting a check in the box represents your digital signature.
Registration Agreement *
By checking this box I agree to the following terms: Please sign below to certify that you are over the age of 13 or are the legal guardian of the above player.