2019 El Korah Shrine Game Registration Form

Personal Information

Player's First Name:

Player's Last Name:

Player's Birth Date:

Player's Age:

Player's Height:

Player's Weight:

Parent/Guardian Name:

Street Address:

City:

State:

Zip/Postal Code:

Player's Phone Number:

Player's Email:

Football Information:

Select Game:    8-Man All Star Game   11-Man All Star Game

School Name:

Jersey Number:

Activities:

Sponsors
Each player is asked to collect $ 75.00 in sponsorships to help defray the costs of the game. Sponsors will be recognized in the game program listed next to the player profile. Each player will be given four (4) game tickets with the sponsorship money. Player tickets will be available for pick up at the player BBQ and the game at the “Will-Call” Window.

Sponsor Names:

Medical

Doctor's Name:

Doctor's Phone Number:

Medications:

Allergies:

Known Medical Conditions:

Primary Emergency Contact:

Relationship to Player:

Primary Contact's Phone Number:

Secondary Emergency Contact:

Relationship to Player:

Secondary Contact's Phone Number:

Insurance

Company:

Plan or Group Number:

Policy Number:

Street Address:

City:

State:

Zip Code:

Phone Number:

Please Read:

El Korah Shrine Game Medical Release (Opens in new window)

I have read and agree with the El Korah Shrine Game Medical Release.

Sportsmanship Agreement (Opens in new window)

I have read and agree with the Sportsmanship Agreement