Challengers Medical History and Release

Challengers Medical History and Release
Player Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Gender *

Male Female

Parent / Guardian Name *

First Name Last Name
Relationship *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Home Phone Number *

Area Code Phone Number
Mobile Phone Number *

Area Code Phone Number

Additional Contact Information
Parent / Guardian Name (2)

First Name Last Name
Relationship
Email
example@example.com
Home Phone Number

Area Code Phone Number
Mobile Phone Number

Area Code Phone Number
Emergency Contact *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number

Medical Contact Information
Insurance Provider *
Policy Number *
Group Number
Doctor Name
Phone Number

Area Code Phone Number
Hospital

Medical History
Medical History
Please list any allergies/medical problems, including those requiring maintenance medications. (ie. Asthman, Diabetes, Seizure Disorder)
Medication
Name, Dosage, Frequency

Authorization & Acknowledgement
I understand that it is my responsibility to update any medical changes pertinent to my child.

I understand that information submitted in this form will be electronically transmitted and stored. That Dyer Girls Softball League or Tri-Town Challengers are not responsible for data that may be inappropriately accessed.

I further authorize my child to be treated by certified emergency personnel.

I also understand that protective equipment cannot prevent all injuries that a player might receive.
I hereby acknowledge and agree *
Name *

First Name Middle Name Last Name Suffix
Today's Date

Month Day Year
Date
Should be Empty: