Poland Swim Club
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We must have a medical form on file for each player before being permitted to practice.
Player's Full Name
(Required)
Age as of 6/1/2024
(Required)
Date of Birth
(Required)
Shirt Size
(Required)
YS
YM
YL
AS
AM
AL
AXL
Check here if this is their first year on tennis team.
New player
Street Address
City
State/Zip
Mother’s Name
Employer
Work or Cell Number
Father’s Name
Employer
Work or Cell Number
Contact if parents are unavailable: relationship/phone #
Doctor’s Name
Address
Phone Number
Health History: Please list all allergies (drug and/or food).
Does your child have any of the following conditions?
Asthma
Ear Infections
Kidney Disease
Diabetes
Orthopedic
Epilepsy
Strep Throat
Neurological
Heart Disease
Please explain any serious or chronic illness:
Known physical, emotional or learning problems:
Any conditions that coaches should be aware of:
Please list all medications taken regularly:
I, the undersigned parent/legal guardian of the above-mentioned participant indicated by the legal signature below, state that said participant is physically able to participate and has my permission to participate on the Poland Swim Club Tennis Team.
Consent to Treat: I give my consent to the Poland Swim & Tennis Team and its representatives to obtain medical care from any licensed physician, hospital, or clinic for the above-mentioned participant for any injury or illness that could arise during participation in Poland Tennis Team activities. I also give permission for ambulance transfer if needed.
Parent/Guardian Signature
(Required)
Parent/Guardian Name
(Required)
First
Last
Relationship to Player
Date
MM slash DD slash YYYY