SIMLEY BLUE LINE CLUB FALL CLINIC ENROLLMENT & WAIVER FORM   2020/2021
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Players First and Last Name:
Parents First and Last Name:
Home Address
Phone number
Health Insurance and Policy #
Family Physician and phone number
Family Dentist and phone number
MEDICAL HISTORY (ILLNESS, INJURIES, MEDICATIONS, ALLERGIES)
Emergency Contact #1 name/phone number
Emergency Contact #2 name/phone number
Permission to Administer Emergency Care: As the parent/legal guardian of the above player, I request that in my absence, the named player is admitted to any hospital or medical facility for diagnosis and treatment. If an emergency transport is deemed necessary, I also give my permission to transport the participant to the hospital or medical facility that will fulfill the necessary treatment of the player. I also request any authorized physicians, athletic trainers, first-aid personnel, nurses, and dentists, to perform any diagnostic procedures, operative procedures, and x-rays of the above minor. I have been given no guarantee as to the results of examination or treatment. Our insurance carrier and I accept any and all responsibilities for all costs associated with the medical care of the above player.
Parent/Guardian Name and Date
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