Medical Information Form
Please completely fill out this health information form. You must complete an individual form for each player in your family.
Player Information
First Name
*
Player's First Name
Last Name
*
Player's Last Name
Birthdate
*
-
Month
-
Day
Year
Player's Birth Date
Gender
Please Select
Female
Male
Non-binary
Player's Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent/Legal Guardian Information
Parent/Guardian 1 Name
*
First Name
Last Name
Relationship to Player
*
Mobile Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Parent/Guardian 2 Name
First Name
Last Name
Relationship to Player
Mobile Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
If parent(s) or legal guardian(s) cannot be reached during an emergency, please contact:
Emergency Contact 1
*
First Name
Last Name
Emergency Contact 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Player
Emergency Contact 2
First Name
Last Name
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Player
Player Emergency Medical Information
Player's Primary Care Physician
*
First Name
Last Name
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Physician Office Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Parent Insurance Company Name:
*
Parent Insurance Company Policy #:
*
Parent Insurance Company Group ID #:
*
The purpose of collecting the information listed below is to ensure that emergency medical personnel have details of any medical problem which may interfere with or alter treatment.
Hospital Preference:
*
Date of last Tetanus Toxoid Booster:
*
-
Month
-
Day
Year
Please list any allergies/medical problems, including those requiring maintenance medication (i.e. Diabetic, Asthma, Seizure Disorder).
Rows
Diagnosis Name
Medication Taken
Dosage Amount
Frequency of Dosage
Medical Diagnosis 1
Medical Diagnosis 2
Medical Diagnosis 3
In case of emergency, if our family physician listed above cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel(i.e. EMT, First Responder, E.R. Physician):
*
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Date
-
Year
-
Month
Day
Date
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