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Unified Sports Intent To Enter Form

Team Name:
School:
Telephone:
Address:
City/Town:
Zip Code:
Event(s) you wish to enter
(maximum of two per team):
Number of Wheelchairs/Walkers:
Roster:
Name Date of Birth M/F Athlete/
Partner
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Name of Principal:
Name of Coach:
Coach's Direct/Cell Telephone:
Coach's e-mail:
Practice Schedule:
CERTIFICATION
By checking this box the listed coach certifies that the students listed in the above form have satisfied
the State Health Statutes and local regulations regarding physical examinations and are physically fit to participate.