Buffalo Lacrosse Academy : Create an Account

Please fill out this form carefully. An email will be sent to the athlete and the parent 1 email address with a link required for account activation. It will also contain an account number, the username, and password of the account you just created.

Account Information
Choose a Username (must be at least 6 characters)
Choose a password (must be at least 6 characters)
Repeat your password (must be at least 6 characters)
Player Information
First Name*:
Last Name*:
Middle Initial:
Date of Birth:	Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Graduation Year (player rises to next grade on July 1 of every year)	2004 2005 2006 2007 2008 2009 2010 2011 2012 - Grade 12 2013 - Grade 11 2014 - Grade 10 2015 - Grade 9 2016 - Grade 8 2017 - Grade 7 2018 - Grade 6 2019 - Grade 5 2020 - Grade 4 2021 - Grade 3 2022 - Grade 2 2023 - Grade 1 2024 2025 2026 2027 2028
Address*:
City*:
State/Province*:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH ON OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip*:
Player Phone Number (optional):
Player Email*:
Re-type Player Email*:
Primary Position*:	Attack Midfield Defense Goalie
School attending in NEXT school year (2011-2012)*:
US Lacrosse Number (optional):
Parent/Guardian 1 Information
First Name*:
Last Name*:
Relation to Applicant*:	Father Mother Grandparent Guardian Step-Father Step-Mother Family Friend Other
Primary Telephone*:
Secondary Telephone*:
Email (this email will be used for ALL official communications, please enter an address checked frequently)*:
Re-type Email*:
Parent/Guardian 2 Information
First Name:
Last Name:
Relation to Applicant:	Father Mother Grandparent Guardian Step-Father Step-Mother Family Friend Other
Primary Telephone:
Email:
Emergency Contact Information
First Name*:
Last Name*:
Relation to Applicant*:	Father Mother Grandparent Guardian Step-Father Step-Mother Family Friend Other
Primary Telephone*:
Secondary Telephone*:
Medical Information
Primary Doctor*:
Primary Doctor's Phone*:
Insurance Provider*:
Policy Number*:
Insurance Number*:
Other Medical Information (current medications, medical/food allergies, medical conditions, etc.):
Required for Extra Security
Enter the letters you see in the image: