On-Line Medical Form

On-Line Medical Form

Medical Release and Waiver

Parent or Guardian Authorization

Date *
In case of emergency, if family physician cannot be reached, I hereby authorize:
Athlete’s Name *
Date of Birth *
To be treated by another qualified, licensed physician who is available.
Family Physician *
Physician Phone *
Physician Address
Allergies * Yes No
If Allergies please list
Insurance *
Hospital *
Tetanus Toxoid Booster * Yes No
Date of last Booster *
Sign by Parent or Guardian *
Verification *  


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