Challengers Medical History and Release

Challengers Medical History and Release
Player Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale

Parent / Guardian Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
Mobile Phone Number*

Area CodePhone Number

Additional Contact Information
Parent / Guardian Name (2)

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

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number

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

Area CodePhone 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 NameMiddle NameLast NameSuffix
Today's Date

MonthDayYear
Date
Should be Empty: