2004 WPSLA & WPMSLA Upper Atlantic Lacrosse
Tournament - Under 15
(For 9th Graders that meet the age requirement)
Name: __________________________________________
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Phone: ____________________
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| Address: ________________________________________ |
E-mail: ____________________
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City: _____________________
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State: _____
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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 for the tryout
on May 2, 2004, and if selected, any practice associated with the team and
the tournament on June 26-27, 2004.
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 associated practices and the Upper Atlantic Lacrosse
Tournament in Downingtown, PA on June 26-27, 2004.
Parent Signature:_____________________________________
Date:________________________