If during the course of my child's activities in volleyball, they should become ill or sustain an injury
| I hereby authorize the SPIRIT VBC instructors and coaches to obtain emergency medical/dental care | YES NO |
| I will assume financial responsibility for the bills incurred. | YES NO |
| My Insurance Company Name | |
| Parent/ Guardian NAME | |
|
Athlete's Medical and Health History |
|
| Is athlete allergic to any medications? | YES NO |
| If Yes, what? | |
| Is the ATHLETE currently taking any medications | YES NO What |
| Any medical conditions we should be aware of | YES NO What |
| Tetanus | YES NO When |
| Family Physician Name | |
| Physician Tel # | |
| Emergency Tel # | () - |
|
Instructions to follow in case of Emergency |
|
Parent/ Guardian signature _________________________ Date _______________
PRINT THIS PAGE AND MAIL IT IN WITH YOUR APPLICATION & PAYMENTS
