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Duluth East Boys Soccer B & C Registration 2023
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* Indicates required question
Player First Name
*
Your answer
Player Last Name
*
Your answer
Grade
*
12th
11th
10th
9th
8th
7th
Required
School
*
Duluth East High School
Ordean East Middle School
Other:
Required
Birthdate
*
MM
/
DD
/
YYYY
Address
*
Your answer
Parent/Guardian Name #1
*
Your answer
Parent/Guardian #1 Email
*
Your answer
Parent/Guardian #1 Phone Number
*
Your answer
Parent/Guardian #2 Name
Your answer
Parent/Guardian #2 Email
Your answer
Parent/Guardian #2 Phone Number
Your answer
Emergency Contact Name If Parent/Guardian Is Unavailable
*
Your answer
Emergency Contact Phone Number
*
Your answer
List of Any Allergies/Medical Issues Coaching Staff Should Be Made Aware Of
*
Your answer
In the case of a serious accident or illness and I cannot be reach, I authorize doctors indicated to give necessary treatment
*
Yes
Name of Doctor
*
Your answer
Phone Number of Doctor
*
Your answer
Name of Dentist
*
Your answer
Phone Number of Dentist
*
Your answer
Insurance Company
*
Your answer
Policy Number
*
Your answer
If given the option, would you prefer your child is taken to St. Mary's/Essentia or St. Luke's?
*
St. Mary's/Essentia
St. Luke's
No Preference
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