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Knight Hoops 2024-25
Consent for Medical Treatment and Release and Hold Harmless
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* Indicates required question
Player Name (Last, First)
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Player Grade
*
Choose
3
4
5
6
7
8
Player Gender
*
Female
Male
Parent Name (Last, First)
*
Your answer
Parent Email
*
Your answer
Parent Phone
*
Your answer
Emergency Contact & Phone
*
Your answer
Medical Insurance Provider (i.e., Aetna, Blue Cross)
*
Your answer
Insurance Name, Group/Policy #
*
Your answer
Policy Holder Name
*
Your answer
Consent for Treatment, Release and Hold Harmless
Do you agree to the above Consent & Release?
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Yes
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Concussion Form
Have you reviewed the Concussion Form above and agree?
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