Miracle League Signup

Player First Name *

Player Last Name *

Date of Birth *

Month

Day

Year

Please Provide Disability *

Please list the use of any adaptive equipment:

Is your child... *VerbalNon-Verbal

What school does your child attend?

Street Address

Apartment, suite, etc

City

State

ZIP Code *

Country

Parent First Name *

Parent Last Name *

Main Phone *(##########)0 / 10

Additional Phone(##########)0 / 10

Email Address *

Please list health conditions, allergies, dietary restrictions, and any special instructions regarding your child:

What do we need to know in order to safely and successfully work with your child? What PRECAUTIONS, SPECIAL INSTRUCTIONS, RESTRICTIONS, OR BEHAVIORS, etc., do we need to know about? Are there any effective strategies or procedures that would be helpful in working with the player?

Any other information you think is important to know? Comments? Special Requests? **Please note: not all requests can be honored***

Emergency Contact Name(s): *

Emergency Contact Phone(s): *(##########)

Buddy (please CHOOSE ONE OPTION below): *I/my child has a BuddyI need help finding a BuddyIf you have a Buddy for your child, please have them register so that we can account for them. In the "special requests" box, please state which Player they will be a Buddy for.

Registration

If you are unable to make an online payment or would like a different form of payment, please contact us to make arrangements.

For any questions, please call (209) 900-4515 or email [email protected]