Rush Athletic Performance Registration 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.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Name

First NameLast Name
Relationship to Athlete
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Known Medical Conditions/Injuries
Allergies
Medications
Program Selection
Please select the program(s) you're enrolling in
Health Insurance (if doing injury evaluations/treatments and not doing self pay rate of $120/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.
Signature
Date

MonthDayYear
Date
Should be Empty:

Form