NYSSRA Health INFO Summary
Please complete all items and press Submit at the end of this form.
Athlete First Name *
Your answer
Athlete Last Name *
Your answer
Athlete Date of Birth *
MM
/
DD
/
YYYY
Athlete Address
Street, City, State, Zip
Your answer
Mothers Full Name *
Your answer
Best phone number to reach Mother *
Your answer
Fathers Full Name *
Your answer
Best phone number to reach Father *
Your answer
Alternate Emergency Contact *
Name and phone number in case we cannot reach a parent.
Your answer
Primary Physicians Name *
Your answer
Physicians Phone Number *
Your answer
If athlete has any allergies, please list them here *
If NONE, Write NONE
Your answer
If athlete takes any medications, please list them here *
if NONE, Write NONE
Your answer
Date of last Tetanus Shot *
Your answer
Date of Last Physical *
Must be within the past 2 years
Your answer
Does athlete have any medical conditions that would limit activites *
Required
Health Insurance Company *
Your answer
Policy Holder *
Your answer
ID/Policy Number *
Your answer
Health Insurance Phone Number *
From Insurance Card
Your answer
Permission to Treat and to release this information in emergencies *
By checking the Yes box below you give NYSSRA staff permission to use their best judgement to obtain medical treatment for my son/daughter in the case of an emergency. You also give permission to release the information given to appropriate medical facilities as required.
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service