Medical Waiver Form

STEP 1:Player Contact Information

Player First Name

Player Last Name

Email Address

Telephone Number

Address

City

Zip Code

STEP:2 Parent Information

Mother's Name

Mother's Phone

Father's Name

Father's Phone

Mother's Email

Father's Email

STEP 3: Player Medical Information

Medical Insurance? Yes No

Medical Insurance Carrier

Player's Doctor

Date of Birth

Emergency Contact

Emergency Phone

Is Player allergic to any types of medicine?

Physical or medical problems?

STEP 4: Verification

Disclosure

Please Initial here:

Message

Leave a message:

Please check your email. You should have received your completed medical form. Please sign this medical waiver and bring this to tryout.

Thank you