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Team Camp Athlete's name:___________________________ Athletes position:_________________________ Parent's Name(s):_________________________ E-mail: _________________________________ Address:_______________________________ City:___________________________________ State/Zip:_______________________________ Home Phone:(_____)______________________ School/City:_____________________________ Grade: (08-09)____________________________ School: _______________________________________
Please fill out the permission to treat form to the right and send this page with $40 (please make checks payable to NEWLHS Volleyball Camp) to: NEW LHS VOLLEYBALL 10 CAMP Questions? Please Call:
Paul Steinhaus I look forward to seeing you at camp. God bless, |
Permission to Treat Form I authorize camp and/or school personnel to transport my son/daughter to a physician's office and/or emergency room for treatment in the event that emergency medical care is needed while s/he is involved in the NEWLHS Volleyball camp. Further I authorize the PHYSICIAN and HOSPITAL STAFF to treat my son/daughter, as they deem necessary in the emergency situation. Parent/Guardian Signature: __________________________________ Date: _____________________________ Insurance Carrier: __________________________________ Policy #:___________________________ Known Allergies:_________________________ Medical Conditions and/or Medications _______________________________________ Father's Full Name: ________________________ Father's emergency phone:__________________ Mother's Full Name:_______________________ Mother's emergency phone:_________________ Family Doctor's phone:_____________________ Family Dentist's phone:_____________________
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