Legal Name *
Legal Name
Please provide if you currently hold WFTDA Insurance. Type Not Available if you do not hold WFTDA Insurance.
Address *
Address
Birthday *
Birthday
Cell Phone *
Cell Phone
Emergency Contact 1 *
Emergency Contact 1
Emergency Contact 1 Phone *
Emergency Contact 1 Phone
Emergency Contact 2 *
Emergency Contact 2
Emergency Contact 2 Phone *
Emergency Contact 2 Phone
Primary Care Physician *
Primary Care Physician
Primary Care Physician Phone *
Primary Care Physician Phone
Please list any and ALL medical conditions that the league needs to be aware of (if none) write "NONE"
Please list any food or drug allergies (If none) type "NONE" below.
Statement of Truth *
I certify that all of the above information is true and correct and that false application information may result in termination of league membership. I have read and understand all the contents of the Membership Packet. I agree to adhere to the rules and code of conduct it has laid forth and accept the consequences should I fail to comply with these rules. CHECK ONE BELOW