Prep Clinic Registration

Name: __________________ DOB: ______________________ Address: ____________________________________________ Phone Number: ______________ Cell: ____________________ Medical Insurance: ____________________________________ Policy Number: _______________________________________ List any current and/or previous injuries: ____________________________________________________ List any medications you are currently taking: ________________________________________________________________________________________________________ List any allergies: ____________________________________________________ Parent Signature: ____________________ Date: ___________ Athlete Signature: ____________________ Date: ___________