Current Health Form printable pdf download

Arsenal Wrestling Club Health Form

1. All information must be completed in order to participate in Arsenal Wrestling Club. A parent/guardian must provide all

form. A doctor’s signature is not required.

requested information,

the form, and a

parent/guardian must sign the

2. The Health Form

must be brought to practice no later than Tuesday, September 27th.

PROGRAM _____ARSENAL WRESTLING CLUB________________

DATES(S)___________________________________

WRESTLER’S AGE________

DOB_____________

NAME OF WRESTLER

FATHER’S NAME ____________________________

MOTHER'S NAME

ADDRESS

____________________________________________________

CITY

__________________________

STATE _________

ZIP _________________

EMAIL ADDRESS: __________________________________

CELL PHONE# ___________________________________

MOTHER'S WORK#

FATHER'S WORK# __________________________________

LIST ADULT(S) WRESTLER IS AUTHORIZED TO BE RELEASED TO

_________________________________________________________________________________________________________

NAME OF ALTERNATE CONTACT PERSON (OTHER THAN PARENT) ______________________________________________

TELEPHONE # OF ALT. CONTACT___________________ RELATIONSHIP TO WRESTLER OF ALT. CONTACT ________________________

LIST ANY MEDICATION, FOOD, OR ENVIRONMENTAL ALLERGIES ______________________________________________

LIST ANY MEDICATION(S) BEING TAKEN. PLEASE INCLUDE DOSAGE & REASON FOR MEDICATION _________________

_________________________________________________________________________________________________________

LIST ANY ORTHOPEDIC INJURIES WITHIN THE PAST YEAR AND DESCRIBE NATURE & SEVERITY OF THE INJURY.

PLEASE GIVE DATE OF INJURY AND A BRIEF EXPLANATION ______________________________________________

_________________________________________________________________________________________________________

FAMILY PHYSICIAN __________________________________

PHYSICIAN'S TELEPHONE # __________________________

DATE OF LAST PHYSICAL EXAM _____________________

DATE OF LAST TETANUS BOOSTER___________________

HEALTH INSURANCE COMPANY

_____________________________________________

HEALTH INSURANCE GROUP AND POLICY #’s ________________________________________________________________

NAME OF PERSON WHO IS PRIMARY HOLDER ______________________________________________________________

WITH MY SIGNATURE BELOW:

 I verify that all of the above information is accurate to the best of my knowledge.

 I authorize Arsenal Wrestling Club and Athletic training staff to provide medical treatment for my child.

 I verify that my child may participate in any and all AWC-related activities and events, and that my authorization does

not conflict with any medical advice or concerns expressed by my child’s physician.

________________________________________________

___________________________________

SIGNATURE OF PARENT/GUARDIAN

DATE

Current Health Form

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