ELAC Athlete Registration

First Name:
Last Name:
SID: [Numbers only!]
Date of Birth: [mm/dd/yyyy]
Contact Phone: [(xxx) xxx-xxxx]
Address:
City:
State: Zip:
Email:
Sex:
Do you have medical insurance?
 Do you have dental insurance?
Are you covered by any state regulated insurance such as Medi-Cal or Covered CA?