:: Santana Dotson Foundation ::

HOUSTON H.E.A.T. / FOOTBALL SELECT ONLINE REGISTRATION:

Please fill out the registration form below to register for the Houston H.E.A.T. Select Football League. Cost is $225.00. After you submit this form you will be taken to a payment page where you can pay your $75.00 deposit online using a credit card or PayPal.

Participant Information:

Participant First Name:

Participant Last Name:

Participant Gender:

Participant Birthday:

Participant Age by Sept 1 2011:

Football Experience:

Height:

Weight:

Jersey Size:

Short/Pants Size:

Guardian Information:

Guardian First Name:

Guardian Last Name:

Guardian Email:

Guardian Cell Phone:

Guardian Address:

Relationship To The Child:

How Did You Hear About Us:

Emergency Contact:

Medical Information:

Medical Issues:

Insurance Information:

Insurance Company:

Insurance Card Number:

Primary Holder:

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