Participant Name / Birth date: __________________________________________________ Weight: _____________
Assumption
of Risk and Consent for Treatment
I
understand that there is an inherent risk of injury with my participation and
contact football, and that this injury may lead to permanent disability or
death. In the event of routine of
emergency health examinations diagnostic procedures, treatment of illness,
and/or injuries, permission is herby granted to treat the athlete above by the NFL
Youth Football Fund (“JPD”) medical staff, physicians associated with other
community facilities as needed.
Name of
Parent / Guardian: ___________________________________________ Date:__________________
Signature
of Parent / Guardian:________________________________________ Date:__________________
Signature
of Student: __________________________________________ Date:
Emergency
Contact #:_(_____)_________________________
Medical
Insurance Information
Indicate
the status of your personal health insurance coverage. If covered, the information indicated below must be
provided for all applicable policies.
______I am
not covered by a health/accident insurance policy.
______I am
covered by my own health/accident insurance policy.
______ I am
covered by my parent’s health/accident insurance policy.
Health
Insurance Company Name & Address:
______________________________________________________________
___________________________________________________________________________________________________
Group #:
_______________________________________ Policy
#: __________________________________
Physician Consent
Height:
______________ Weight:
_________________ Blood
Pressure: _____________
Allergies:
___________________________________________________________________________________________
Medication
student-athlete is taking:
______________________________________________________________________
Previous
Medical Conditions:
___________________________________________________________________________
___________________________________________________________________________________________________
Previous
Orthopedic Conditions: _________________________________________________________________________
_____
Student-athlete cleared for all full contact physical activities (full contact
football)
_____
Student-athlete restricted from physical activities, reason and/or conditions
for clearance (if any)
Conditions
for clearance (if any):
________________________________________________________________________
___________________________________________________________________________________________________
Signature
of Doctor: ______________________________________________ Date:
*(Doctor’s
stamp of approval also required)