Player:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Gender:
*
Please Select
Male
Female
Parent(s)/Legal Guardian Name:
*
First Name
Last Name
Relationship:
*
Parent(s)/Legal Guardian Name:
First Name
Last Name
Relationship:
Player Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number:
*
Please enter a valid phone number.
Home Number:
Please enter a valid phone number.
Work Number:
Please enter a valid phone number.
Email:
example@example.com
PARENT OR LEGAL GUARDIAN AUTHORIZATION:
In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel(i.e. EMT, First Responder, E.R. Physician):
Family Physician:
*
Phone Number:
*
Please enter a valid phone number.
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital Preference:
*
Parent Insurance Co.:
Policy No.:
Group ID#:
League Insurance Co.:
Policy No.:
League/Group ID#:
If Parent(s)/Legal Guardian cannot be reached in case of emergency, contact:
Name:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Relationship:
Name:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Relationship:
Please list any allergies/medical problems, including those requiring maintenance medication (i.e. Diabetic, Asthma, Seizure Disorder).
Medical Diagnosis
Medication
Dosage
Frequency of Dosage
1
2
3
4
Date of last Tetanus Toxoid Booster:
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.
Authorized Parent/Legal Guardian Signature
Date:
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: