Health form

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These fields are for player identification only


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Parent Info

Business Address *

Conference Information

Other emegency contact

Relationship to Participant

Health history

Heart Defect/Disease *

Convuisions *

Diabetes *

Hipertension *

Mononucleosis *

Bleeding/Clotthing Disorder *

Frequent Ear Infection *

Diseases

Chicken Pox *

Measles *

German Measles *

Mumps *

Any food Allergies we should be aware of?

(Please list the foods you are allergic to and any details):

Are you taking or cartyng any medicine for these allergies like Epipen or anything else?

Operations or serious injury (Description & dates): *

Disability or chronical recurring illness: *

Current medication taking: *

List Name & Dosage

Insurance information

Do you carry family medical/hospital insurance? *

Agreement

I, the undersigned parent/guardian, do hereby grant permission for my son/daughter, named above, to attend the conference named above. In order that my son/daughter may receive the proper medical treatment in the event that he/she may sustain injury or illness during the period of the above conference, I hereby authorize the conference staff to obtain or provide medical treatment for my son/daughter for such injury or illness during the conference, and I hereby hold A.F.B.E. as well as its representatives, harmless in the exercise of this authority.

I further understand that there is always a possibility that my son/daughter may sustain physical illness or injury while at a conference. If this occurs, I hereby authorize conference staff and/or A.F.B.E. representatives to refer my son/daughter to a medical treatment center (hospital, etc.). I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my son/daughter for physical illness
or injury that he/she may sustain during the conference.

Understanding that there is always a possibility that my son/daughter may sustain physical illness or injury, I acknowledge and understand that my son/daughter is assuming the risk of such physical illness or injury by his/her participation, and I further release A.F.B.E. and its representatives from any claims for personal illness or injury that my son/daughter may sustain during the conference.

I further acknowledge and understand that my son/daughter will be responsible for his/her failure to abide by the rules and regulations of the conference named above or of A.F.B.E.

I accept this policy:

*
Please fill out all fields with star *