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: ___________