Athlete *

First Name

Last Name

Primary Guardian *

First Name

Last Name

Primary Guardian Phone *

(###)

###

####

Physician Phone *

(###)

###

####

Permission to Participate *

Participant, has my permission to participate in training, competition, events, activities and travel sponsored by HHCVC I approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed above. I understand and agree that this document will be kept in the possession of authorized adult team personnel and that reasonable care will be used to keep this information confidential. I agree to allow the authorized adult team personnel to release this information in the event of a medical emergency to a third party medical provider. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above.

Yes

No

Concussion Acknowledgement *

In the past 24 months, have you been tested, diagnosed and/or treated for a concussion:

yes

no

Date Authorized

MM

DD

YYYY