Group
Number _____________________________________ Policy Number
_______________________________________ Medical Information
Player First Name ____________________________________ Last Name __________________________________________
Date of Birth_______________________ M ____ F _____ Age ________
Current Mailing Address _____________________________________________State _______ Zip Code _______________
Home Phone Number _____________________________________ Work Phone Number ___________________________
Mobile Number ________________________________________________
Contact Name ________________________________________________Relationship to Participant _________________
HEALTH INSURANCE INFORMATION
Carrier Name & Address ___________________________________________________________________________________
Group
Number _____________________________________ Policy Number
_______________________________________
Subscriber Number _________________________________Telephone Number ___________________________________
PRIMARY DOCTOR’S INFORMATION
Phone Number _____________________________________________
Address ______________________________________________State_________ Zip Code _______________________
CURRENT MEDICATION _______________________________________________________________________________
MEDICATION ALLERGIES ______________________________________________________________________________
FOOD ALLERGIES ______________________________________________________________________________________
Other Allergies Explain ________________________________________________________________________________
Previous Illness ________________________________________________________________________________________
Previous Surgeries _____________________________________________________________________________________
MEDICAL CONDITIONS Asthma __________Anemia _________ Diabetes _________Blood Pressure ___________
Other Explain __________________________________________________________________________________________
This information must be completed and signed before enrolling in any program conducted by Extreme Tennis Academy.
Date _____________________ Parent/Guardian Signature __________________________________________________