2025 FCA ALL-STARS                                      Medical & Emergency Contact Info
Please respond to the following regarding your current health since your most recent U.I.L. physical exam and your emergency contact information:
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ALL-STAR First Name *
ALL-STAR Last Name *
Date of Birth *
MM
/
DD
/
YYYY
ALL-STAR Sport *
ALL-STAR Team *
What is the date of your last U.I.L. physical? *
MM
/
DD
/
YYYY
Are you feeling healthy and able to participate in multiple practices and a full contact contest? *
If "No" to above question, please explain *
Type "None" if answer above is "Yes"
Have you suffered any injury or illness since your last pre-participation physical exam which resulted in your being unable to participate in athletics or normal daily activities? *
If "Yes" to the above question, please describe the details including diagnosis and date of injury/illness below... *
Type "None" if answer above is "No"
Referring to the question above, have you been cleared by a Physician to participate in athletics from the injury/illness listed above?  If "Yes" please send a copy of the release from your Physician to NETXFCA@gmail.com *
Can you think of any reason why you shouldn't be able to participate in the FCA ALL-STAR practices and/or game? *
If "Yes" to above question, please explain *
Type "None" if answer above is "No"
Are you suffering from any medical problems or under the care of a Dr. at the present time? *
If "Yes' to above question, please explain *
Type "None" if answer above is "No"
Are you allergic to any foods or medications? *
If "Yes" to above question, please explain *
Type "None" if answer above is "No"
Are you taking any supplements or medications, prescription or over the counter regularly? *
If "Yes" to above question, list what you are taking *
Type "None" if answer above is "No"
Emergency Contact Person *
Someone other than you
Relationship *
Phone (cell preferably) *
number must be in the required format xxx-xxx-xxxx
Address *
City *
Zip Code *
2nd Emergency Contact Person (not the same person listed above) *
Type "none" if you don't have a 2nd emergency contact
Relationship *
Type "none" if you don't have a 2nd emergency contact
Phone (cell preferably) *
number must be in the required format xxx-xxx-xxxx. Type 000-000-0000 if you don't have a 2nd emergency contact
Is there anything else you'd like to tell us?
ALL-STARS Signature (type full name) *
Typing name is an electronic confirmation that the above information is accurate
Parent Signature (type full name) *
Typing name is an electronic confirmation that the above information is accurate
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