Player Information

Player First Name *

Player Last Name *

Gender *

Male

Female

Date of Birth * +

Street Address *

City *

State *

Zip Code *

Shirt/Jersey Size *

School Information

School Name *

Current Grade *

Current Educational Level *

Middle School

High School

Current Age *

Select proper Division

DAYS and TIMES *

Tuesdays, Wednesdays and Thursdays from 4pm to 7pm

Please help us track statistics so that we can better serve our community,

Nationality/Race *

Do you qualify for free or reduced school lunch? *

Yes

No

Are you interested in the Food For Families Program? *

Yes

No

Parent/Legal Guardian Information

First Name *

Last Name *

Phone Number *

Email Address *

Relationship to child *

Does you family receive any of the following? Please select all that apply: *

In order to be eligible for "services for non-placed children", a child/family's gross income may not exceed 400 percent of the Federal Poverty Guidelines (FPG) for the family unit size. Using the table below, provide a "YES" or "NO" in Column 4 in the corresponding row for the family size as to whether the child/family's income is less than the annual or monthly amount for the family size. (Family unit includes biological, adoptive or step-parents, specified relatives, or non-relative court designated legal custodians and full, half, and/or adopted siblings living in the home under the age of 18 plus the TANF child). This is a self-declared means test. No verification except the response of the family is required. If the family DOES NOT receive assistance, please select the category that applies below: *

A Family Unit Size of 1- 400% of FPG (gross) (Annually) Less than $49,960 400% of FPG (gross) (Monthly) Less than $4,163	A Family Unit Size of 2- 400% of FPG (gross) (Annually) Less than $67,640 400% of FPG (gross) (Monthly) Less than $5,637
A Family Unit Size 3- 400% of FPG (gross) (Annually) Less than $85,320 400% of FPG (gross) (Monthly) Less than $7,110	A Family Unit Size 4- 400% of FPG (gross) (Annually) Less than $103,000 400% of FPG (gross) (Monthly) Less than $8,583
A Family Unit Size 5- 400% of FPG (gross) (Annually) Less than $120,680 400% of FPG (gross) (Monthly) Less than $10,057	A Family Unit Size 6- 400% of FPG (gross) (Annually) Less than $138,360 400% of FPG (gross) (Monthly) Less than $11,530
A Family Unit Size 7- 400% of FPG (gross) (Annually) Less than $156,040 400% of FPG (gross) (Monthly) Less than $13,003	A Family Unit Size 8 400% of FPG (gross) (Annually) Less than $173,720 400% of FPG (gross) (Monthly) Less than $14,477
Does NOT APPLY to ME

Is the child a U.S. Citizen or a legal status immigrant? *

YES

NO

What Documentation source do you have to prove citizenship? *

Birth Certificate

INS

CIS

Self Declaration

Is the child living in the home of a parent, other adult specified relative or a court designated legal custodian? *

YES

NO

Additional Parent/Legal Guardian Information

First Name

Last Name

Cell Phone Number

Email Address

COVID-19 WAIVER WILL BE EMAILED SEPARATELY

Start Date (Subject to Change) *

TUESDAY, SEPTEMBER 7th at 4:00pm

LOCATION: 141 W. Somerset Ave. Phila 19133

Waiver *

I AGREE to the waiver: By checking the "I Agree to the waiver" box, you acknowledge that participation in the program exposes your child to a possibility of personal injury. You, the PARENT/LEGAL GUARDIAN, being fully aware that participation in the program exposes your child to a possible risk of personal injury, hereby release The Lighthouse, Inc and all affiliates from any and all liability from property damage, personal injuries, or other claims arising from or in connection with your participation in the program including claims that are known and unknown, foreseen and unforeseen, future or contingent. You acknowledge that you have read and fully understand the Injury Waiver and General Release Form. This agreement shall be binding on you, your spouse, your children, legal representatives, heirs, successors and assigns.

Youth Small	Youth Medium	Youth Large	Youth X-Large	Adult Small	Adult Medium
Adult Large	Adult X-Large

American Indian or Alaska Native.	Asian.
Black or African American.	Native Hawaiian or Other Pacific Islander.
White.	Biracial
Latino or Hispanic	N/A

Parent	Guardian	Legal Custody	Temporary Custody
Relative

TANF (CASH ASSISTANCE)	SSI	FOOD STAMPS	MEDICAID
NONE