AUTHORITY TO TREAT AND WAIVER
One per family
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Player 1 Full Name *
Player 1 Date of Birth *
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Player 2 Full Name
Player 2 Date of Birth
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Height and Weight (HS only)
The above basketball player has been granted permission to attend and participate in and with teams, leagues, tournaments, camps, and other basketball activities sponsored by the Western Iowa Express. The player has received a physical examination by a physician and is physically fit to participate. I hereby give my consent, in case of injury, to have an athletic trainer, medical doctor, nurse, hospital, or clinic provide the player with medical assistance and/or treatment, and agree to be responsible financially for the reasonable cost of such assistance and/or treatment.
By typing my name below, I acknowledge the above statement as the parent/guardian of the above player(s). *
Parent 1 Name *
Parent 1 Home Phone
Parent 1 Cell Phone *
Parent 2 Name *
Parent 2 Home Phone
Parent 2 Cell Phone *
In an emergency when parent(s)/guardian cannot be reached, please contact:
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Relationship to Player *
Allergies *
Medical Problems *
Family Physician *
Family Physician Phone Number *
Insurance Carrier and Policy Number *
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