Medical Authorization Form

Athlete Name *
Athlete Name
Parent/Guardian Phone
Parent/Guardian Phone
Called ONLY if parent/guardian is unreachable
Emergency Contact Phone
Emergency Contact Phone
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
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
By entering my name and pressing "Submit" I electronically sign this Medical Authorization Form
By entering my name and pressing "Submit" I electronically sign this Medical Authorization Form
Date
Date