FORMS 

WAUKESHA KNIGHTS

 

PLAYER INFORMATION

 

Name: ______________________________ Age: ________ D.O.B: __________

 

Parent/ s Name: ___________________________________________________

 

Address: _________________________________________________________

 

City: _______________________    Zip Code: _____________________________

 

Home Phone #: ____________________

 

Mother’s E-mail Address: ______________________________________________

 

Mother’s Cell Phone #:________________________________________________

 

Father’s E-mail Address: _______________________________________________

 

Father’s Cell Phone #: _________________________________________________

 

Attending School: _______________________________    Grade: _____________

 

Player lives with: (   ) Both Parents   (   ) Mother    (   ) Father    (   ) Legal Guardian

 

 

Emergency Contact:

 

Name: ______________________________   Address: ______________________

 

Work Phone #: ____________  Home Phone #: _______________Cell Phone #:_____________

 

Relationship to Player: _________________________________

 

 

Physician and Insurance information:

 

Family Doctor: ______________________________   Phone #: __________________________

 

Address: ______________________________________________________________________

 

Insurance Provider: _____________________________________________________________

 

Policy #: ______________________________________________________________________

 

Policy Owner: __________________________________________________________________

 

Group #: ______________________________________________________________________

 

 

Medical Information

 

Please indicate if your child has any health problems, takes any medication or is allergic to any medicine or food? : _____________________________________________________________

 

______________________________________________________________________________

 

 

 

Parent Signature: ________________________________   Date: ___________