Dreamplex Dragons – Registration Form

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Dreamplex Dragons Power Soccer - Registration

"*" indicates required fields

Participant Information

Please enter the following information about the person participating in the program.
Name*
Date of Birth*
Disabilities*
What is the primary disability associated with the participant? (if applicable)
(Optional) Please feel free to expand on the participant's disabilities, or any other information about the participant, here. Include anything you would like the instructors/coaches to know.
Does the participant have their own power chair they'd like to use?*
Does the athlete currently receive Medicaid benefits or services? This information is requested only for grant reporting purposes and will be kept confidential. You may choose not to answer.*
Does the athlete currently receive free or reduced-price school meals? This information is requested only for grant reporting purposes and will be kept confidential. You may choose not to answer.*
Please select the household income range that best represents the athlete’s household. This information is requested only for grant reporting purposes and will be kept confidential. You may choose not to answer.*
Do you have a uniform from a previous season that still fits?*
Uniform Jersey Size*

Participant Contact Information

Please enter the contact information for yourself, the parent, or caregiver
Name*
(e.g. Self, Parent, Caregiver)
Address*

Emergency Contact Information

Please enter the contact information in case of emergency. (someone who will NOT be in attendance at the event and NOT the same person listed above)
Name*
This person will be contacted, only in the case of emergency

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