Form

Form
Athlete Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Team*
Parent/Guardian Contact Info
Name*

First NameLast Name
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact
Name*

First NameLast Name
Relationship to Athlete*
Phone Number*
Please enter a valid phone number.
Medical Information
Known Medical Conditions/Injuries
Allergies
Medications
Program Selection
Please select the program(s) you're enrolling in*

Full Access (Open Gym, competitions, soccer skills & injury prevention classes) - Monthly price - $70Injury evaluations - $90/session or health insurance acceptedIndividuals - $45/session
Health Insurance (if doing injury evaluations/treatments and not doing self pay rate of $90/session)

Upload picture of Front and Back of your Insurance Card
I hereby authorize my child to participate in Rush Athletic Performance programs. I acknowledge that physical activity carries inherent risks and agree to release Carr Physical Therapy, its staff, and affiliates from liability for injury sustained during participation. I understand that emergency medical treatment may be provided in the event of an emergency if I cannot be reached. I certify that the above information is complete and accurate.
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Date*

MonthDayYear
Date
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Athlete Information