2004 WPSLA Ohio Underclassmen Tournament, Rutgers
Team Camp, Keystone Games
Name: __________________________________________
|
Phone: ____________________
|
| Address: ________________________________________ |
E-mail: ____________________
|
City: _____________________
|
State: _____
|
ZIP: __________
|
Grade just completed: ______
|
US Lax #: ________
|
Position: A
M D LSM G
|
High School: ____________________
|
* * * * * * * * * * * * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
MEDICAL CONSENT
I hereby give consent for routine or emergency diagnostic procedures
and treatment of my child in case I am not available. I acknowledge that I
am responsible for all reasonable charges in connection with the care and
treatment rendered during this period. This consent is good for the dates
associated with the Ohio Games, Rutgers Team Camp, and Keystone Games and
any practices held in preparation of these events.
Parent Signature:_____________________________________
Date:________________________
Insurance Information:
Policy Holder's Name:______________________________________ Phone
:___________________
Address:_________________________________________________
City:_________________________ State: PA
Zip:______________
Insurance Company:______________________________________
Group #:__________________
Employer:______________________________________________
Agree. #:__________________
Address:_________________________________________________
City:_______________________ State:_____
Zip:______________
Player's Health History:
Allergies:______________________________________________________________________________
Medications (dosage/frequency):____________________________________________________________
Current or chronic illnesses:___________________________________________________________
Other:________________________________________________________________________________
Player's Physician:__________________________________
Phone #:____________________________
Player's SSN:______________________________________
* * * * * * * * * * * * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
PARENTAL PERMISSION
I give my permission for the player previously named
to participate in the tryouts, any associated practices and the
Ohio Underclassmen Tournament, Rutgers Team Camp, and/or Keystone Games
.
Parent Signature:_____________________________________
Date:________________________