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Athlete Name *

SPORT *

Grade/ Age *

Date of Birth *

School *

Parents/ Guardians Name *

Parent/ Guardian Full Address *

Parent/ Guardian Home Phone *

Parent/ Guardian Cell Phone *

Email address *

Emergency Contact (if different from above):

Name *

Relationship to Athlete *

Full Address *

Home Phone *

Cell Phone *

Medical Information

Allergies

Medications

Medical Insurance Company

Group #

Subscriber ID# *

Preferred Hospital Name *

Primary Care Provider Name

Phone #

check one *

I give permission to treat my child (using the above providers) in the event of an Emergency.
I do not give permission to treat my child in the event of an emergency

Parent/ Guardian Signature: *

Print Name *

Date *

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