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)~--------