5N2 Footy Academy Medical Release & Emergency Contact Form

5N2 Footy Academy Medical Release & Emergency Contact Form

Provide your student’s health details and consent for participation in half-day or full-day PE activities.
Student Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
PE Program Type
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Authorized Adult

First NameLast Name
Additional Authorized Adult Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions, Allergies, or Medications
Authorization and Release Statement: I hereby authorize my child to participate in the PE program and release the 5N2 Academy, academy staff, and Everyday Church from liability for any injury, illness, or any misconduct that may occur. I confirm that all medical information provided is accurate.
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty: