CONSENT FOR ATHLETIC PARTICIPATION & MEDICAL CARE •Entire Page Completed By Pati ent

Athlete Information Last Name_ _ _ _ _ _ _ _ _ _ _ __ Sex: [ ] Male [ ] Female

Grade _ _ _ __

First Name

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Age _ __

Ml _ __

DOB _ _/_ _/_ _

Allergies _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Medications

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Insurance _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Policy Number _ _ _ _ _ _ _ _ _ _ _ __ Group Number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Insurance Phone Number _ _ _ _ _ _ _ __

Emergency Contact Information Home Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _-1{.::::C~ity;/..,j)~--------