ADULT Medical Release & Waivers
FC Padre '21 Turkey Shootout
Players DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Players Name
*
First Name
Last Name
Known Allergies (including allergies to medicines)
Any other medical problems which should be noted:
Family Physician
*
Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Carrier
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature
Submit
Should be Empty: