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Slam Dunk Birthday Party
Slam Dunk Birthday Party Consent, Release & Waiver
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* Indicates required question
Email
*
Your email
Participant Name
*
Your answer
Parent's Name
*
Your answer
What is the last name of the Birthday Party Host?
*
Your answer
Date of Slam Dunk Birthday Party
MM
/
DD
/
YYYY
Participant's Gender
*
Male
Female
Participant's Date of Birth
*
MM
/
DD
/
YYYY
Address
Street Address
*
Your answer
City / State / Province
*
Your answer
Postal / Zip Code
*
Your answer
-
Phone Number
*
Area Code + Phone Number
Your answer
Emergency Number
*
Area Code + Phone Number
Your answer
Email
*
Your answer
Physician Name
*
Your answer
Physician Phone Number
*
Your answer
Health Insurance Provider
*
Your answer
Policy Number
*
Your answer
List known medical conditions that could impair full participation (print N/A if none):
*
Your answer
List medications currently taken (print N/A if none):
*
Your answer
List known medical conditions that could impair full participation (print N/A if none):
*
Your answer
List medications currently taken (print N/A if none):
*
Your answer
List known allergies (print N/A if none):
*
Your answer
Has Participant ever been diagnosed with/treated for a concussion within the last 12 months:
*
Yes
No
If yes, please provide the month/year, cause of concussion, outcome and other relevant details:
Your answer
Send me a copy of my responses.
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