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2022 MSFPA Summer League Emergency Contact Information and Informed Consent
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* Indicates required question
Email
*
Your email
Athlete's First Name
*
Your answer
Athlete's Last Name
*
Your answer
ATHLETE'S Birthdate MM/DD/YYYY
*
MM
/
DD
/
YYYY
Address
*
Your answer
City
*
Your answer
State
*
Illinois
Zip
*
Your answer
Phone
*
Your answer
Email
*
Your answer
List TWO to contacts in case of emergency
Parent or guardian's name
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Mobile Phone with Area Code
*
Your answer
Work Pone with Area Code
*
Your answer
2nd Contact full name
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip code
*
Your answer
Mobile Phone
*
Your answer
Work Phone
*
Your answer
Relationship to Athlete
*
Your answer
Medical Insurance Company
*
Your answer
Policy Number
Your answer
Primary Physician's Name
*
Your answer
Phone with Area Code
*
Your answer
Hospital Preference
*
Your answer
Is the Athlete allergic to any drugs? If so, what?
*
Your answer
Does athlete have any other allergies? (bee stings, peanuts, etc?
*
Your answer
Do you suffer from asthma, diabetes, epilepsy, other? If so, please list
*
Your answer
Is the athlete on any medication? If yes, please list.
*
Your answer
Does athlete wear contact lenses or glasses?
*
Contacts
Glasses
No
Parent or Guardian's Signature (type full name)
*
Your answer
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