JACKSON CATHOLIC MIDDLE SCHOOL
2010-2011 Fall Sports Registration Form

Note:  Please include the area code in brackets for telephone information

SPORT:     GRADE: 

PLAYER INFORMATION

First Name:     Middle Name:      Last Name:

DOB:      Age:      Sex: 
              (mm/dd/yy)     

Parish:      School Last Attended:       School (if OTHER previously selected):  

Street Address:      City:      Zip: 

Telephone:      Player Lives With: 


FATHER  INFORMATION

First Name:      Last Name:   

Home Phone (only if different from player):      Cell Phone:      Work Phone: 

RESIDENCE ONLY IF DIFFERENT FROM PLAYER
Street Address:      City:      State:      Zip: 

E-Mail Address: 

MOTHER  INFORMATION

First  Name:      Last Name:   

Home Phone (only if different from player):      Cell Phone:      Work Phone: 

RESIDENCE ONLY IF DIFFERENT FROM PLAYER
Street Address:      City:      State:      Zip: 

E-Mail Address: 

GRANDPARENT/LEGAL GUARDIAN INFORMATION
ONLY IF PLAYER RESIDES w/ GRANDPARENT or LEGAL GUARDIAN

First Name:      Last Name:   

Home Phone (only if different from player):      Cell Phone:      Work Phone: 

Street Address:      City:      State:      Zip: 

E-Mail Address: 

MEDICAL INFORMATION

Family Physician:      Physician Telephone: 

Physical Taken:  (select yes only if the physical was taken after 4/15/2010)     Date of Physical: 

Physical on File in School Office:    (select yes only if the physical form has been turned into the school/athletic office)

Name of Emergency Contact:    Emergency Contact Relationship:  

Emergency Contact Phone: