Player Name
*
First Name
Last Name
D.O.B
*
MM
DD
YYYY
Player Grade Level
Email
*
Player Gender
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent Name
*
First Name
Last Name
Phone
*
(###)
###
####
Parent Email
*
Emergency Contact Name
*
First Name
Last Name
Relationship To Player
*
Emergency Contact Phone
*
(###)
###
####
Insurance Company *
Medical Insurance Group Number
Medical Insurance Policy Number
Policy Holder
First Name
Last Name
Medical Insurance Phone Number
Does the player have any allergies that we need to be aware of?
*
Select
Yes
No
Does the player have any other medical conditions that we need to be aware of?
*
Select
Yes
No
If you answered yes on either of the questions above... please elaborate below....
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? If yes, please explain below.
*
Select
Yes
No
Electronic Signature *** *
*
Medical Treatment Authorization
I understand that I will be notified in the case of a medical emergency involving my child. However, in the event I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that Coastal Athletics are not responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I agree to notify Coastal Athletics staff of any health changes that would restrict my child's participation. I also understand that the adult supervisors reserve the right to restrict my child from participation if they do not feel my child is within the physical capabilities. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.
If You Have Any Questions or Concerns... please specify below.
