Sign Up for Harlem Lacrosse

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Thank you for being part of our team!
Leer el formulario en español.
Li fòm lan an kreyòl.

Player Information

Player's First Name *

Player's Last Name *

Gender *

Date of Birth *

Month

Day

Year

Team

What school does your child attend? *

Which team is your child on? *

Current Grade *

What is your student ID number?

Sizes

Jersey Size *

Shorts Size *

Shoe Size *

Player Info

Player Email Address *

Player Cell Phone Number *

May we contact the player on their cell phone? *

Yes, text only

Yes, calls only

Yes, calls and text

Is it okay for your child to sign themselves out after practice and travel home alone? *

Is there anyone who cannot pick up your child or drive them home from trips or programming? (including Harlem Lacrosse staff) *

Medical Information

Please list any allergies your child has. *

Please list all medications your child is taking. *

Please list all of the medical conditions your child has, even if they are not serious. *

Please share any illnesses or injuries your child has had in the past. *

Please list any other medical concerns we should be aware of. *

Doctor's Name *

Doctor's Phone Number *

Health Insurance Provider *

Health Insurance Policy Number *

Policy Holder Name *

Parent/Guardian Contact Information

Enter contact information for parents/guardians and emergency contact for this player.

Parent/Guardian 1

Please fill out this information about yourself.

First Name *

Last Name *

Street Address *

City *

State *

Postal Code *

Phone Number *

Email Address *

Parent/Guardian 2

Please fill this about about your child's other parent or guardian, if applicable. If not, please leave it blank.

First Name

Last Name

Street Address

City

State

Postal Code

Phone Number

Email Address

Additional Contact Information

Please share the information of one other person we can contact if there is an emergency involving your child.

Additional Contact Name

Additional Contact Relationship to Player

Additional Contact Phone Number

Additional Contact Email Address

Student and Family Information

We have several additional questions about your child and your family. We are asking these questions because Harlem Lacrosse's donors and supporters sometimes want to know these facts about the group of students who participate in Harlem Lacrosse. We realize these are personal questions, so we thank you very much if you are willing to share this information with us. We will never share your personal information with anyone. When we talk about these facts, we will only share percentages for all HL participants (for example, "20% of Harlem Lacrosse participants receive special education services.”)

What is the main language your family speaks at home? *

Please list all languages your child speaks. *

Does your child use English Language Learner (ELL) services at school? *

Does your child receive special education services at school? *

If yes, what services do they receive?

Has your child ever repeated a grade? *

What is your child's race/ethnicity? Please select all that may apply. *

Other Ethnicity:

What is the highest level of education that any of your child's parents or guardians has received? *

What is your total annual household income? *

Is there anything else we need to know to help support your child? *

Today's Date

Month

Day

Year

Leave this field blank