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2024 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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* Indicates required question
ALL-STAR First Name
*
Your answer
ALL-STAR Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
ALL-STAR Sport
*
Baseball
Cheer
Football
Softball
ALL-STAR Team
*
Blue
Red
Cheer
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?
*
Yes
No
If "No" to above question, please explain
*
Type "None" if answer above is "Yes"
Your answer
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?
*
Yes
No
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"
Your answer
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
james.rapp@christushealth.org
.
*
Yes
No
Does not apply to me
Can you think of any reason why you shouldn't be able to participate in the FCA ALL-STAR practices and/or game?
*
Yes
No
If "Yes" to above question, please explain
*
Type "None" if answer above is "No"
Your answer
Are you suffering from any medical problems or under the care of a Dr. at the present time?
*
Yes
No
If "Yes' to above question, please explain
*
Type "None" if answer above is "No"
Your answer
Are you allergic to any foods or medications?
*
Yes
No
If "Yes" to above question, please explain
*
Type "None" if answer above is "No"
Your answer
Are you taking any supplements or medications, prescription or over the counter regularly?
*
Yes
No
If "Yes" to above question, list what you are taking
*
Type "None" if answer above is "No"
Your answer
Emergency Contact Person
*
Someone other than you
Your answer
Relationship
*
Your answer
Phone (cell preferably)
*
number must be in the required format xxx-xxx-xxxx
Your answer
Address
*
Your answer
City
*
Your answer
Zip Code
*
Your answer
2nd Emergency Contact Person (not the same person listed above)
*
Type "none" if you don't have a 2nd emergency contact
Your answer
Relationship
*
Type "none" if you don't have a 2nd emergency contact
Your answer
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
Your answer
Is there anything else you'd like to tell us?
Your answer
ALL-STARS Signature (type full name)
*
Typing name is an electronic confirmation that the above information is accurate
Your answer
Parent Signature (type full name)
*
Typing name is an electronic confirmation that the above information is accurate
Your answer
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