Medical & Liability Release
Prior to your upcoming class, lesson, practice, and/or try-out with Northstar Elite, we kindly request that you fully complete our Medical & Liability waiver form
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Email *
Participant Name: *
Date of Birth *
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Home Address: *
City/State/Zip *
Cell Phone: *
E-mail Address: *
Mothers Name: *
Mothers Cell Phone: *
Fathers Name: *
Fathers Cell Phone: *
In case of emergency, please contact:  *
Cell Phone: *
Current Health Insurance Carrier: *
Policy Number:  *
Family Doctor:  *
Doctors Contact Info:  *
Have you had any serious illness, surgery or injury? *
If yes, please explain below:

Do you have any medical problem or allergies that may interfere with physical classes? 

 *
If yes, please explain below:
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