2004 WPSLA & WPYLA Middle School Keystone Games
(For 7th & 8th Graders. This form will also
enable you to tryout for the U-15 Team)
Name: __________________________________________
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Phone: ____________________
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| Address: ________________________________________ |
E-mail: ____________________
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City: _____________________
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State: PA
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ZIP: __________
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Graduation Year: _______
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Position: A
M D LSM G
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School: ______________________
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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 from July 22,
2004 through July 24, 2004 and any other practice days that may be added.
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:______________________________________
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PARENTAL PERMISSION
I give my permission for the player previously named to participate
in the tryouts, any practices and Keystone Games on July 23 & 24, 2004.
Parent Signature:_____________________________________
Date:________________________