Athletics
Sports Physical
Email address *
School 18-19 school year *
Student Name:
Last name, First name, Middle initial *
Your answer
Social Security Number (not required)
Your answer
Address:
Number & Street *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Telephone
Parents Home Phone *
Your answer
Grade
18-19 School Year *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Sex
Parent's (or Guardian) Information:
Father - if not applicable put N/A *
Your answer
Father's Place of Employment
Your answer
Father's Address
Your answer
Father's Phone Numbers
Work
Your answer
Home
Your answer
Mother - if not applicable put N/A *
Your answer
Mother's Place of Employment
Your answer
Mother's Address
Your answer
Mother's Phone Numbers
Work
Your answer
Home
Your answer
Next closest relative to give consent if parents are not available *
Your answer
Phone *
Your answer
Medical Insurance Information
Must provide proof of medical insurance. DO NOT LEAVE BLANK or LIST LIFE INSURANCE
Company *
Your answer
Policy #/Group # *
Your answer
Subscriber *
Your answer
Relationship to Student *
Secondary Insurance Company: If any
Your answer
Policy#/Group#
Your answer
Subscriber
Your answer
Relationship to Student
Parent/Guardian Signature: By typing your name below is acknowledgement that the above is true and accurate to the best of your knowledge. *
Your answer
Date *
MM
/
DD
/
YYYY
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