Wildcats Volleyball Club Medical Information Form (Jo Season) printable pdf download

Wildcats Volleyball Club Medical Information Form (JO SEASON)

Name of Player/Member: ____________________________________________________________________

Address: __________________________________________________________________________________

City: ____________________________________ State: ___________ Zip Code: ______________________

Date of Birth: ________________________ Sex: __________ Height: ___________ Weight: _____________

Parent or Legal Guardian: _____________________________________________________________________

Address: __________________________________________________________________________________

City: ____________________________________ State: ___________ Zip Code: ______________________

Phone Number: _____________________________________________________________________________

Please give the name of your health/accident insurance carriers and appropriate policy certificate number:

Name of Carrier: ___________________________________ Certificate #: ______________________________

Does this person have any chronic or acute medical problems? _________________

Please explain:

List any allergies to food, pollen, or medicine:

List any medications being taken at the present:

Medical Release Form

My daughter has permission to participate in all functions conducted by the Wildcats Volleyball Club during the 2002/2003

USAV Junior Olympic Volleyball season. The USAV Junior Olympic Volleyball season includes the months of November 2002

and extends through July of 2003. I fully realize that injury or illness could result from or during participation of activities

conducted by the Wildcats Volleyball Club. In case of such accident or illness, I give permission for my child to be given

medical treatment as deemed appropriate. I will assume responsibility for any medical bills incurred by my child while

participating in any and all activities pertinent to the Wildcats Volleyball Club.

Parent or Legal Guardian’s signature (required)

Date

Wildcats Volleyball Club Medical Information Form (Jo Season)