Sport * - Select -BaseballMen's BasketballWomen's BasketballBeach VolleyballMen's Cross CountryWomen's Cross CountryFootballMen's GolfWomen's GolfMen's SoccerWomen's SoccerSoftballMen's Swimming & DivingWomen's Swimming & DivingVolleyballMen' Track & FieldWomen's Track & FieldMen's Water PoloWomen's Water PoloWrestling Delta Student ID * Student Information First Name * Last Name * Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Age Sex Male Female Student Address Street Address * City * State * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code * Student Contact Info Phone Number (Home) Mobile Number (Cell) Personal E-mail (not your Delta e-mail) Parent Information Father's Name Father's Mobile Number (cell) Father's Work Number Mother's Name Mother's Mobile Number (cell) Mother's Work Number Emergency Contact InformationContact #1 Name Relationship Home Phone Work/Cell Phone Contact #2 Name Relationship Home Phone Work/Cell Phone Student Health Info Please provide other health information needed in case of an emergency. Include such conditions as: serious allergies, asthma, diabetes, ear and eye problems, heart conditions, seizure disorders, orthopedic conditions: List any Conditions Here Are you allergic to any medications? Yes No If Yes, Please list Are you currently on any medications? Yes No If Yes, Please list Insurance Information Permission is hereby authorize San Joaquin Delta College to obtain through a physician of its own choice any emergency medical care that may be necessary while he/she is participating or traveling under San Joaquin Delta College supervision. I also authorize the College Athletic trainer to administer those treatments deemed necessary by the team physician. Are you covered under your own OR your parent’s health insurance policy? * Yes No Insurance Company Name Insurance Policy Holder Name Group/Policy# Type of Insurance Plan * HMO PPO Other Signatures Student Signature * Please type your Full Name Date * Month MonthNov Day Day18 Year Year2024 Parent/Guardian Signature (If student is under 18 years of age.) Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202320242025 Relationship to Student Parent Legal Guardian Other CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Math question * 1 + 1 = Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
