Health History Form

Permission for Emergency Medical Treatment:  In the event of an emergency, every effort will be made to contact a parent/guardian or emergency contact.  If no contact can be made, I hearby give authorization to Colorado Sting Basketball Club, LLC to seek treatment for my child by a licensed physician.  I know of no reason(s) why my daughter may not participate in prescribed activities except as noted on the health history form.  If permission for emergency medical treatment is not given, please prepare a signed statement providing the reason, a release of liability, and alternate instructions and attach to this form.


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Date
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Email Signature
By typing my email in this box, If no contact can be made, I hearby give authorization to Colorado Sting Basketball Club, LLC to seek treatment for my child by a licensed physician.
Participant Name
Date of Birth
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Participant Cell Phone
Participant Email
Parent Name
Parent Cell Phone
Parents Email
Physician Name
Physician Phone
Insurance Carrier
Policy Number
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