Insurance And Medical Information Form printable pdf download

MISSOURI STATE SOCCER SCHOOL

INSURANCE AND MEDICAL INFORMATION FORM

Name of Participant: ______________________________________________ Participant’s Date of Birth: __________________

Participant’s Emergency Contact: ______________________________________(_____)________________________________

Name

Phone Number

Relationship

Participant’s Emergency Contact: ______________________________________(_____)________________________________

Name

Phone Number

Relationship

Participant’s Insurance Company: _________________________________________ Policy Number: _____________________

**Please attach a copy of insurance card

Policy Holder: _____________________________ Policy Holder’s Relationship to Participant: __________________________

Policy Holder’s Date of Birth: ______________________ Policy Holder’s Social Security Number: _______________________

Policy Holder’s Address (if different from Participant’s): __________________________________________________________

List of Current Medications: _________________________________________________________________________________

Does the Participant require assistance in taking any medication? ______ Yes ______ No

**If you answered yes, please attach a sheet to this form detailing the name of the medication, when and how often it is supposed

to be taken, and the dosage amount.

List of Allergies: __________________________________________________________________________________________

List of Physical Disabilities/Restrictions: _______________________________________________________________________

I, ____________________________, state that I have completed the Medical Information Form and have completely and

accurately disclosed all of the information requested herein. I further acknowledge that in the event of an emergency, this

information will be provided to a healthcare provider in order to allow said provider to render medical treatment to the Participant.

I acknowledge that the only knowledge Southwest Missouri Sports Camps, Inc. has of the Participant’s medical condition is

contained in the information that I have provided on this Form.

_________________________________________________________________

DATE: __________________________

Signature of Participant or Parent or Guardian of Participant

Return to:

Missouri State Soccer School

P.O. Box 7055

Springfield MO 65801-7055

MISSOURI STATE SOCCER SCHOOL IS OWNED AND OPERATED BY SOUTHWEST MISSOURI SPORTS CAMPS, INC.

Insurance And Medical Information Form