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Athlete First Name *
Athlete Last Name *
Email Address *
Address *
Phone Number *
Age *
Parent/Guardian Name *
Parent/Guardian Contact Number *
Emergency Contact Name (Other than Parents) *
Emergency Contact Phone Number *
Health Insurance Carrier
Policy/Group Number
Any intolerance to drugs or medication?
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If "Yes" please describe, if "No" please write "None"
Any previous illness, condition, disability or injury the gym staff should be aware of?
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If "Yes" please describe, if "No" please write "None"
Please list any medications our child is currently taking:
Please list any allergies.
I will allow Valley staff to provide my child with the following medications: (Check all that apply) *
I give my athlete (named above) permission to participate in athletic and related activities to be conducted by Valley Athletics. To my knowledge my child has no physical restrictions that would inhibit her/him from this activity. I further acknowledge and understand that I am assuming the risk of such physical illness, injury or even death that my child may sustain from this activity. In the event that my child is injured, needs immediate medical attention, and I cannot be reached, I give Valley Athletics permission to authorize transportation to the nearest medical center for medical attention and I will assume the costs of such transportation and medical attention. *
Please type your name below acknowledging you agree to the above statement. *
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