Medical Authorization Form

Athlete Name *

Athlete Name

First Name

Last Name

Parent/Guardian *

Parent/Guardian Phone

(###)

###

####

Emergency Contact

Called ONLY if parent/guardian is unreachable

Emergency Contact Phone

(###)

###

####

Medical Conditions

Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test Test test

I Agree

By entering my name and pressing "Submit" I electronically sign this Medical Authorization Form

First Name

Last Name

Date

YYYY