Port City Athletics

Port City Athletics
MEDICAL RELEASE FORM
Name of Cheerleader/Athlete*
First Last
Primary Doctor's Name*
First Last
Doctor's Phone*
Preferred Hospital*
Medical/Health Insurance Information:
Name of Policy Holder*
First Last
Employer*
Name of Insurance Provider*
Insurance Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Member ID#*
Group ID#*
List all Current Medications:
List all Allergies:
List All Medical Conditions And/Or Injuries That May Limit or Prohibit Participation in Any PCA Activity:
Date of Last Tetanus Booster:*
Month
Day
Year
Date of Last Physical:*
Month
Day
Year
In case of emergency, I hereby authorize my child to be treated by a qualified physician and/or taken to the hospital. I certify that my child is fully covered by the insurance policy listed above, and I agree to bear the costs of any injury to my child sustained as a result of any activity through PortCity Athletics.*
In case of emergency, I hereby authorize my child to be treated by a qualified physician and/or taken to the hospital. I certify that my child is fully covered by the insurance policy listed above, and I agree to bear the costs of any injury to my child sustained as a result of any activity through PortCity Athletics.
I agree
Parent/Guardian Signature*
Date*
Month
Day
Year
Phone*

LEVEL 1