Individual Event Permission And General Release Of Claims (Page 2 of 2) in pdf

Individual Event Permission And General Release Of Claims Page 2

Student Contact & Emergency Information:

_______________________________________________________________________________________

Home Address

City/State

Zip

_______________________________________________________________________________________

Student Home Phone Number

Student Cell Phone Number

_______________________________________________________________________________________________________

Father

Work Phone #

Cell Phone #

_______________________________________________________________________________________________________

Mother

Work Phone #

Cell Phone #

_______________________________________________________________________________________________________

If not parent, legal guardian

Work Phone #

Cell Phone #

_______________________________________________________________________________________________________

Other emergency contact (after parents)

Phone #

_______________________________________________________________________________________________________

Medical Insurance Company

Medical Policy #

Policyholder Name

_______________________________________________________________________________________________________

Student’s Physician name and phone #

Medical Information (Include allergies, diabetes, physical limitations, diseases, or other conditions):

_____________________________________________________________________________________

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Individual Event Permission And General Release Of Claims Page 2