Players Name_________________________________________________  DOB_____________________

Grade______________  Shirt size       YM        YL         YXL       AS         AM         AXL  ​​

Parent/ Guardian _________________________________________________________________

Home Phone____________________ Cell_______________________ Email_____________________________

If a game is canceled due to weather how should we contact you?_______________________________________

Emergency Contact  ( if parent can not be reached)___________________________________________________

Relationship__________________________  Phone_______________________________

Preferred Doctor ____________________________________________  Phone ___________________________

Is your child currently under a doctors care or taking medication?   Yes     No    Explain_______________________

Allergies? _______________________    Medical Condition _______________________________________

Do you have health insurance covering your child?     _________  Yes  __________  No

Do we have permission to transport your child by ambulance if necessary?  _____Y  _____ N 

Medical Release:  In case of emergency I hereby authorize my child to be treated by Certified Emergency

personnel (ie;  EMT, First Responders, ER Physician,  Hospital Personnel ) _______________________________


________________________________________________________________Parent/ Guardian

Date ___________________________________


The purpose of reporting the above listed information is to ensure that medical personnel have details of any/all

medical problems which may interfere with or alter treatment. ​​​​​