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Athlete Information Form
When completing you'll need your medical insurance information and a few minutes to answer the questions.
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1
Who's your Athlete?
*
This field is required.
Choose only your athlete! Complete one per athlete
Please Select
Alaina Arrington
Allanah Townsend
Allayah Townsend
Analisa Calderon-Logan
Anastasia Calderon-Robinson
Arshauwna Price
Ava Wash
Avah Lockett-Pierce
Gabrielle Miller
Gernie Shannon
Harley Rupert
Harper Rupert
Jael Aria Flowers
Kelisia Hamilton
Kylie Armstead
Morgan Tolbert
Skiilar Evans
Skylar Harris
Zaria Tolbert
Zoë Mercardo
Zora Mercardo
Please Select
Please Select
Alaina Arrington
Allanah Townsend
Allayah Townsend
Analisa Calderon-Logan
Anastasia Calderon-Robinson
Arshauwna Price
Ava Wash
Avah Lockett-Pierce
Gabrielle Miller
Gernie Shannon
Harley Rupert
Harper Rupert
Jael Aria Flowers
Kelisia Hamilton
Kylie Armstead
Morgan Tolbert
Skiilar Evans
Skylar Harris
Zaria Tolbert
Zoë Mercardo
Zora Mercardo
Choose your Athlete's name. If you do not see your Athlete's name please click this form
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2
Athlete Medical Information 1 of 3
*
This field is required.
Please complete each field the very last box is to add additional medical information and list medicines.
List any allergies
Please Select
Yes, glasses only
Yes, contacts only
Yes, glasses and contacts
No
Please Select
Please Select
Yes, glasses only
Yes, contacts only
Yes, glasses and contacts
No
Does your athlete wear glasses or contacts?
Please Select
Yes, somtimes
Yes, almost often
No
Please Select
Please Select
Yes, somtimes
Yes, almost often
No
Does your athlete experience rcurring headaches, double vision, dizziness, blackouts?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Is your athlete Diabetic?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Does your athlete have epilepsy?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete had surgery in the past 3 years?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete had any broken bones in the last 3 years?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Does your athlete have ANY heart problems?
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3
Athlete Medical Information 2 0f 3
*
This field is required.
Please complete each field the very last box is to add additional medical information and list medicines.
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete ever had any ankle problems?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete ever had any knee problems?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete ever had groin/hip problmes?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete ever had should, arm, elbow, or wrist problems?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Does your athlete ever experience back or neck pain?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Does your athlete experience asthma?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Has your athlete seen a doctor for any/all of the condiitons listed?
Please Select
Yes, detailed information below
No
Please Select
Please Select
Yes, detailed information below
No
Is there anyhting not listed that the staff should be made aware of?
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4
Athlete Medical Information 3 0f 3
*
This field is required.
Please complete each field the very last box is to add additional medical information and list medicines.
Please put ALL additional medical information here
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5
Medical Information Confirmation
*
This field is required.
Please note that any information given will remain confidential; unless deemed appropriate/relevant to divulge to appropriate personnel. By signing below you confirm that all the medical information you have provided is updated, accurate, and belongs to the athlete named on the form.
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Parent/Guardian Signature
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6
Athlete Insurance Information
*
This field is required.
Complete all information!
Insurance Carrier
Policy Holder Full Name
Policy Number
Please Select
Yes
No
Please Select
Please Select
Yes
No
Does the staff at Coach Ryan have permission to use this medical insurance information in case of emergency?
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7
Insurance Initials
*
This field is required.
By initialing you confirm that the above information belongs to you and that you give authorization for the staff of Coach Ryan to use this information for your child/athlete in case of an emergency.
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8
Release of liability - Participation Waiver
*
This field is required.
Please complete all fields before submission
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9
Parents Full Name
*
This field is required.
First Name
Last Name
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10
Parent's Signature
*
This field is required.
By signing this I agree to all points checked under the financial obligations agreement and terms of the waiver. I authroize that I am the parent/guardian of the above athlete and confirm all information given is accurate.
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Parent / Guardian Signature
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