SPECIAL DRAGONS


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Special Dragons Registration Form



Athlete’s name: ________________________________
Male/Female (choose one):
Parent/Guardian name: ____________________________
Parent/Guardian e-mail:____________________________
Emergency contact:
Name: __________________________ Phone number: __________________________
Athlete’s date of birth: ______________________________
Address: __________________________________________
Phone numbers:
Home: ________________ Cell: _________________________
Athlete’s diagnosis, if any: _____________________________________
Conditions instructor should be aware of, including limitations regarding physical activity: _______________________________________________________________________ ______________________________________________________________________________ Name of Foundation and Case Manager _____________________________________________ Information provided by: Name: ______________________________ Signature___________________________ Date: __________


Please Send Completed Form To: george@specialdragons.us

George@SpecialDragons.us | Phone: 973 667-8525