Athletics Medical Form
Student Name: *
Your answer
Student email address *
Your answer
Sport(s): *
Required
Phone Number: *
Your answer
Sex: *
Age: *
Your answer
Date of Birth: *
MM
/
DD
/
YYYY
Parent or Guardian's Name: *
Your answer
Parent or Guardian's Email address *
Your answer
Address: *
Your answer
Parent's phone number: *
Your answer
Doctor's Name/phone number/address: *
Your answer
Preferred Hospital: *
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Insurance group number
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Insurance company
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Insurance Id #
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Emergency contact other than parent: *
Your answer
Does student have any special medical conditions? If yes, please explain *
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Is student taking medication? If yes, please explain. *
Your answer
Is student allergic to any drugs? If yes, please specify. *
Your answer
When did student have his/her last tetanus shot? *
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