Dear Returning Student-Athletes and Parents: As a student-athlete, it is necessary for us to gather pertinent medical information in order to determine if you are medically eligible to participate in intercollegiate athletics. Enclosed, you will find a packet of forms that require your attention. When completing these forms, please answer all questions to the best of your knowledge. Below is a list of forms followed by a brief description. If you have any questions, please feel free to contact one of the athletic training staff members via the numbers listed below. As a student-athlete, you will be required to participate in a comprehensive physical exam given by the athletic training staff. Physicals will be held at the Carol & Frank Morsani Center for Advanced Healthcare (on Campus) on three separate dates: June 12th, June 26th and Aug 21st. In order to participate in intercollegiate athletics, you must have all of your medical information turned in along with a physical. 9
HEALTH INSURANCE INFORMATION FORM: A photocopy of both sides of all insurance cards (medical, dental, vision, prescription) must be attached to the completed form.
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STUDENT-ATHLETE PERSONAL INFORMATION FORM: This form provides contact information in the event of an emergency.
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MEDICAL HISTORY: This will inform us of any previous medical problems and hopefully prevent any further problems from occurring.
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BIOLOGICAL TESTING CONSENT FORM: By signing this form, you are indicating your understanding of the program and your agreement to be screened for banned substances. Screening takes place randomly throughout the year for all athletes. Participation in athletics is contingent upon adherence to the program and the signing of the consent form.
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INFORMATION RELEASE AUTHORIZATION FORMS:
These forms gives the athletic training staff permission to release your medical history to team physicians, coaches, athletic staff members, student athletic trainers, parent(s)/ guardian(s), teammates, and professional scouts. These forms are required to be completed only once during your athletic career at USF.
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NCAA AND USF POLICY REGARDING LIABILITY: This form allows us to provide emergency medical care to you and terminate participation for health reasons at any time.
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NOTICE OF PATIENT INFORMATION PRIVACY PRACTICES: This form is informative and may be kept for your records. The notice explains your rights as a patient and how the USF Sports Medicine staff may use your medical information. Please return the acknowledgement page. Deadlines for the return of your medical paperwork are as follows: June 12th physical ⇒ Return paperwork by June 4th, 2010 th June 26 physical ⇒ Return paperwork by June 18th, 2010 st Return paperwork by Aug 13th, 2010 Aug 21 physical ⇒ If you are a fall sport athlete and live near the Tampa Bay area, we strongly recommend you attend the June 12th physical! If you are a fall sport athlete and are unable to attend any of the physicals held in June, Please contact your coach or assigned Athletic Trainer (listed below)to arrange for an alternate physical date and time prior to the start of your season. Once again, if you have any questions please feel free to contact one of us at the phone numbers listed below or in the training room at (813) 974-0514.
Sincerely, Steve Walz Asst. Athletic Director Director of Sports Medicine (813) 974-3506 Football, Baseball Last printed 8/6/2010 8:41 AM
Jennifer Galuski Asst. Athletic Trainer (813) 974-4146 M. Basketball, Softball, Volleyball, Sailing
Keith Abrams Assoc. Athletic Trainer (813) 974-6794 Football, Tennis, M. Soc, Cheer
Donna Jordan Asst. Athletic Trainer (813) 974-4140 W. Basketball, W. Soccer, Track/Cross Country, Golf
Directions to Morsani Building Leffers/Nofsinger/Larry
-Go LEFT on Sycamore -Go LEFT on Holly -Continue straight on Holly -Turn LEFT on Holly when it dead ends -Turn RIGHT on Laurel -Morsani building is on LEFT Offices are located on the 3rd floor
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TO: Parents of USF Student-athletes FROM: USF Sports Medicine RE: HMO Insurance Plans The USF Athletic Department athletic accident policy provides insurance for a student-athlete’s injuries incurred while participating in a USF sanctioned practice or game. This insurance is “EXCESS” or “SECONDARY” to any other collectable group insurance benefits. Any claim for benefits must first be filed with the athlete’s primary insurance company. After the primary insurance has paid all available benefits, the USF athletic insurance company will pay any remaining amounts based on REASONABLE and CUSTOMARY charges. If you have managed care insurance, otherwise known as an HMO, we strongly urge you to change your primary care physician (PCP) to one of our USF team physicians (if you have a HMO family plan, most insurance carriers will allow you to change the PCP for one member of the plan without affecting the PCP for the other members covered by the plan.) Changing the PCP for your son/daughter will benefit you and your family in many ways: 1. Allow your son/daughter easy access to their PCP, as our USF team physicians are located on campus less than a mile from our athletic facilities. 2. Expedite your son/daughter’s medical care by removing the need for a prior approval from another PCP before seeing our team physicians. 3. Cut down on medical costs to you in the event that a non-athletic injury does occur; these injuries and illnesses are not covered by the USF policy and all costs will be the responsibility of the patient. 4. Allow for better communication regarding injuries between all parties involved (including athletic trainers, team physicians, student-athletes and parents.) To switch the primary care physician for your son/daughter, simply contact your insurance carrier at the phone number listed on your insurance card. They will ask you for the name of the physician of which you would like to switch; our head team physician’s name and address is listed below for your convenience. When calling our doctors, please identify yourself as a parent of a USF athlete to expedite the procedure. Please notify the sports medicine department at (813) 974-0514 when the change of the PCP has been made. Additionally, if you have any questions regarding our insurance policy or our team physicians, please do not hesitate to call. Thank you for your attention to this matter. Address and Phone Number: Dr. Eric Coris 12901 Bruce B. Downs Blvd. USF Medical Center Tampa, FL 33612 (813) 974-2201
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University of South Florida Sports Medicine Athlete Medical History Name __________________________________ Date of Birth ____ / ____ / ____
Date
___________________
Sport _______________________________
Family History Does anyone in your family have a history of medical problems? Y / N If yes, explain: __________________________________________________________________ Mother: ________________________________________________________ Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Father: _________________________________________________________ Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Brother(s): ______________________________________________________Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Sister(s): ________________________________________________________Living: Y / N Age of Death: __________ Cause of Death: ________________________________________ Has anyone in your family ever been diagnosed with: Y/N
Sudden unexplained death Relationship: ____________________________ Explain: __________________________________________________________ Y / N Alcohol/Substance Abuse Relationship: ____________________________ Explain: __________________________________________________________ Y / N Asthma Relationship: ____________________________ Explain: __________________________________________________________ Y / N Cancer Relationship: ____________________________ Explain: __________________________________________________________ Y / N Diabetes Relationship: ____________________________ Explain: __________________________________________________________ Y / N Heart Disease (of any kind) Relationship: ____________________________ Explain: __________________________________________________________ Y / N High Blood Pressure Relationship: ____________________________ Explain: __________________________________________________________ Y / N Marfan Syndrome Relationship: ____________________________ Explain: __________________________________________________________ Y / N Migraines/Severe Headaches Relationship: ____________________________ Explain: __________________________________________________________ Y / N Osteoporosis/Bone Disorder Relationship: ____________________________ Explain: __________________________________________________________ Y / N Seizures/Epilepsy Relationship: ____________________________ Explain: __________________________________________________________ Y / N Sickle Cell Disease/Trait Relationship: ____________________________ Explain: __________________________________________________________
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Current Medical Conditions: Y/N
Are you currently under medical supervision for an injury/illness? If yes, explain: __________________________________________________________________
Y/N
Do you have a current ongoing or chronic illness? If yes, explain: __________________________________________________________________
Surgery/Hospitalization: Y/N
Have you ever had surgery? Date: ________________ Date: ________________ Date: ________________
Surgery: ______________________________ Surgery: ______________________________ Surgery: ______________________________
Y/N
Have you ever been hospitalized for a reason other than surgery? Date: ________________ Reason: _______________________________ Date: ________________ Reason: _______________________________
Y/N
Have you ever been advised to have a surgery not yet performed? If yes, explain: _________________________________________________________________
Medications: Y/N
Do you regularly use any prescription medication? If yes, explain: _________________________________________________________________
Y/N
Do you regularly use non-prescription medication? If yes, explain: _________________________________________________________________
Y/N
Do you regularly take any dietary supplements? If yes, explain: _________________________________________________________________
Y/N
Have you ever taken supplements or vitamins to help you gain/lose weight in order to improve your performance? If yes, explain: _________________________________________________________________
Alleriges: Are you allergic to any of the following: Y / N Aspirin Y / N Food (specify) __________________________ Y / N Dust/pollen Y / N Insect stings (specify) _____________________ Y / N Penicillin Y / N Sulfa Drugs Y / N Novocaine Y / N Other Drugs (specify) _____________________
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Illnesses: Have you had any of the following illnesses: Y / N Chicken Pox Date: _______________ Y / N Diabetes Date: _______________ Y / N Hepatitis Date: _______________ Y / N Measles Date: _______________ Y / N Mononucleosis “Mono” Date: _______________ Y / N Pneumonia Date: _______________ Have you ever had any of the following: Y / N Anemia Y / N Sickle Cell Disease/ Sickle Cell Trait Y / N Eye injury or other eye problem Y / N Hearing loss Y / N Severe tooth or gum trouble Y / N Severe skin problems (rash, acne, burns, etc.) Do you have loss or seriously impaired function of any paired organ? Y / N Ear Y / N Eye Y / N Kidney Y / N Ovary Y / N Testicle Y / N Lung Cardiovascular System: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Do you get more fatigued (tired) during exercise, or get fatigued earlier during exercise than your teammates? Do you become more short of breath during exercise than your teammates? Have you ever fainted or passed out during or after exercise? Have you ever had chest pains during or after exercise? Have you ever been told that you have high blood pressure (hypertension)? Have you ever been told that you have a heart murmur? Have you ever been told that you had high cholesterol (hyperlipidemia)? Has a physician ever ordered heart testing (for example: EKG, Echo, stress test, holter monitor)? If yes, please explain:____________________________________________________________ Y / N Have you ever been diagnosed with any type of heart disease (hypertrophic cardiomyopathy, coronary artery abnormality, heart infection, heart valve disease, Marfan’s Syndrome, etc)? If yes, please specify: ____________________________________________________________ Y / N Have you ever been told that you need to take medication before seeing a dentist? Y / N Have you ever had a racing heart or skipped heart beats? Y / N Has anyone in your family died of heart problems or sudden death before the age of 50? If you answered yes to any of the above questions, please explain: ____________________________ __________________________________________________________________________________________________ ________________________________________________________________________
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Respiratory System: Y/N Y/N Y/N
Y/N Y/N
Do you cough, wheeze, have difficulty breathing, or get short of breath during exercise? If yes, how often? _______________________________________________________________ Have you ever been diagnosed with asthma? If so, is your asthma well controlled? Please check one: I have symptoms from my asthma: daily_____ More than twice per week_____ Less than twice per week _____ Hardly ever _____ Do you use an inhaler? If yes, what kind? _______________________________________________________________ Do you have seasonal allergies that require medical treatment or medication?
Neurological System: Y/N
Have you ever had a head injury or a concussion? Date: ___________________ Explain: _________________________________ If so, how many concussions? __________________________________________
Y/N
Have you ever been knocked out, unconscious, or lost your memory? Date: ___________________ Explain: _________________________________
Y/N
Have you ever had a seizure? Date: ___________________ Explain: _________________________________
Y/N
Have you ever had a stinger, burner, or pinched nerve? Date: ___________________ Explain: _________________________________
Heat Illnesses: Y/N Y/N Y/N Y/N Y/N
Have you ever had heat stroke or heat exhaustion? If so, please explain: _____________________________________________________________ Have you ever had muscle cramps caused be the heat? How often? _______________________ Have you ever been dizzy or fainted in the heat? How often? ____________________________ Have you ever been confused in the heat? How often? _________________________________ Have you ever been hospitalized for a heat related condition?
Nutrition: Y/N Y/N Y/N
Do you want to weigh more or less than you currently do? Do you frequently lose weight or gain weight to meet the requirements of your sport? Would you be interested in seeing a sports nutritionist?
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Women Only: What was the date of your last menstrual period? ____________________________________________ When was your first menstrual period? ____________________________________________________ How many periods have you had in the last year? ____________________________________________ What was the longest time between periods in the last year? ____________________________________ My periods are now (circle one): Regular ⇒ every 24-35 days Irregular ⇒ every 36 days or more Absent ⇒ no periods for the past three months Y/N Y/N Y/N Y/N
Are you currently taking a form of birth control? If yes, what kind? _______________________________________________________________ Is there a history of osteoporosis in your family? Is there a history of repeated fracture in anyone in your family? Have you had repeated fractures or repeated stress fractures before?
Protective Devices: Y/N Y/N Y/N Y/N
Do you wear contacts? Do you wear glasses? Do you wear orthotics in your shoes? Do you wear any corrective braces or supports? If yes, what? ___________________________________________________________________
Musculoskeletal System: Have you ever injured any of the following extremities that caused you to miss a week or more participation in your sport? Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N
Hip Groin Thigh Knee Shin/Calf Ankle Foot/Toes Skull/Face Teeth/Jaw Neck Back Shoulder Upper Arm Elbow Forearm Wrist Hand/Fingers
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Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right Left / Right
Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date:
__________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________ __________
Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain: Explain:
______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________
Other Medical Conditions: Y/N
Have you ever been told, for any reason, that you should not participate in sports? If yes, explain: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
Y/N
Do you know of, or believe, there is any reason that should prevent you from participating in intercollegiate athletics? If yes, explain: __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
I certify that the answers to the preceding questions are correct and true to the best of my knowledge. I understand that passing the physical exam does not necessarily mean that I am physically qualified to engage in intercollegiate athletics, but only that the examiner did not find medical reason to disqualify me from participation.
_______________________________________ Signature of Student-Athlete
_______________________ Date
_______________________________________ Signature of Parent/Guardian if under 18 years of age
_______________________ Date
MEDICAL CONSENT Permission is hereby granted to the attending physician, USF Sports Medicine Staff, or other medical personnel to proceed with medical treatment, minor surgical treatment, and x-ray examination. In the event of serious injury or illness, I understand that an attempt will be made by the appropriate medical personnel to contact my parents or legal guardian. If medical personnel are not able to communicate with the responsible party, the treatment necessary for my health will be provided. _______________________________________ Signature of Student-Athlete
________________________ Date
_______________________________________ Signature of Parent/Guardian if under 18 years of age
________________________ Date
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Student-Athlete Health Insurance Information Form Dear Parent/Guardian: We have an established athletic insurance policy providing medical coverage for your son/daughter for injuries that occur while participating in Intercollegiate Athletics. This medical coverage is secondary to medical/dental/vision insurance provided by the parent/guardian. After primary benefits are considered, USF will process the remaining balance for payment. Please complete this form entirely. Please attach copies of all insurance cards, front and back. Athlete______________________________________SS#________________________DOB_________________ Father/Guardian_____________________________________________SS#________________DOB____________ Address_____________________________________________________________________________________ Employer_________________________________________________Work.Phone__________________________ Employer.Address_____________________________________________________________________________ Mother/Guardian___________________________________________SS#_________________DOB____________ Address_____________________________________________________________________________________ Employer________________________________________________Work.Phone___________________________ Employer.Address_____________________________________________________________________________
Medical Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company_________________________________________ Customer.Service#_____________________ Claims.Address________________________________________________________________________________ Member#______________________________________Policy#____________________Group#_______________ PPO or HMO____________ Primary Care Physician_______________________Phone#_______________________
Prescription Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company_________________________________________Customer.Service#_____________________ Claims.Address________________________________________________________________________________ Member#_____________________________________Policy#_____________________Group#_______________
Dental Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company_________________________________________Customer.Service#_____________________ Claims.Address________________________________________________________________________________ Member#_____________________________________Policy#_____________________Group#_______________ PPO or HMO___________Primary Dentist_____________________________Phone#________________________
Vision Insurance
Covered by Father/Mother/Uninsured (circle)
Insurance.Company__________________________________________Customer.Service#____________________ Claims.Address________________________________________________________________________________ Member#_____________________________________Policy#_____________________Group#_______________
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STUDENT ATHLETE PERSONAL INFORMATION Name: ________________________________________________________________ (last)
(first)
USF I.D. #: _________________________
(middle initial)
Birthdate: _______________ (month / day / year)
Year in school: F S J S 5th
Sport: _____________________________
Local Address: _________________________________________________________ (Street / Box #)
(Apt #)
_________________________________________________________ (city / state / zip code)
Local Phone Number: (____) ____________________ Cell Phone Number: (____) _____________________
IN CASE OF EMERGENCY CALL: Name: ____________________________
Relationship: ________________
Address: ______________________________________________________________ (Street / Box #)
(Apt #)
______________________________________________________________ (city / state / zip code)
Home Phone #: (____) _________________ Work Phone #: (____) _________________ Cell Phone #:
(____) _________________
I acknowledge receiving the University of South Florida’s intercollegiate athletic medical policy. I understand the university’s responsibility to a student athlete who becomes injured or ill as a result from participation in intercollegiate athletics. Student Athlete’s Signature: _______________________________
(date)
_________
Parent / Guardian Signature: _______________________________
(date)
_________
(If under 18)
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University of South Florida Intercollegiate Athletics Biological Specimen Testing Consent Form 1. I hereby consent to be tested to determine if I have utilized any substance on the University of South Florida list of banned drug classes as set forth in the University of South Florida’s Substance and Abuse Policy, by providing a biological specimen as requested by the director of intercollegiate athletics or designee. 2. I agree to provide such biological specimens at the time and location and under conditions for collection, as determined by the director of intercollegiate athletics or designee, at various times throughout the year, with or without prior notice. 3. I hereby authorize the director of intercollegiate athletics or designee to send my samples to the laboratory of the university’s choice for actual testing and authorize the director of intercollegiate athletics or designee to receive test results. 4. I hereby authorize the director of intercollegiate athletics or designee to release all information and records, including test results, that may be made or received relating to the screening and testing of my biological specimens to the university’s respective head coach and associate athletic director for sports and program services, or their designees, for their use in supervision and administration of the university’s athletic program. I acknowledge that while certain medical information may be released to the media by virtue of my participation in USF Intercollegiate Athletics, the results of drug tests will not be released or reported. I further acknowledge and agree that my parent/ guardian will be notified of the results of any positive test result(s). 5. I acknowledge that I have read a copy of the University of South Florida Drug Abuse Policy and Procedures, including the University of South Florida Banned Drug Class List, and that I have had an opportunity to ask questions regarding them. I understand the provisions therein and I agree to abide by those provisions including those specifically related to possible penalties for positive test results. 6. I hereby release and discharge the University of South Florida and the Board of Trustees of the State University System of South Florida, their officers, employees and agents from all claims and causes of action created by or arising out of any act or omission related to the implementation of the University of South Florida Drug Abuse Policy and procedures. 7. I have read this Consent Form, understand the terms in it, their legal significance and sign voluntarily. 8. I understand that I may revoke my consent to participate at any time in the University of South Florida Drug Abuse Policy. In doing so, I understand and agree that I will immediately be banned from participation in intercollegiate athletics at University of South Florida and will immediately forfeit any related athletic scholarships or financial aid.
_______________________________________
____________________________
Student Athlete Name (Print)
USF ID Number
_______________________________________ Student-Athlete Signature
______________________________ Date Birth Date
___________________________________________ Parent / Guardian (if under 18 years of age)
______________________________ Date
_____________________________ Sport
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INFORMATION RELEASE AUTHORIZATION I, _____________________, Give consent for my medical records to be released to any USF Team physician involved in the care of my illness or injury; or to a physician appointed by the USF Athletic Training Staff.
Athlete’s Signature: _________________________
Date: ___/___/___
I also give consent for the USF Athletic Training Staff to release medical information to the sports information department, media, or a scout/ representative of any professional or amateur athletic organization seeking such information. I acknowledge that this type of information may be reported in the media as a result of my participation in USF Intercollegiate Athletics, except that no results of drug tests will be released or reported. ( Body part affected by injury or illness ( Nature of the injury (sprain, fracture, etc.) ( Status of the athlete for same day and future competition
Athlete’s Signature: _______________________
Date: ___/___/___
***This release remains valid until revoked in writing and delivered to the Assistant Director of Athletics for Sports Medicine. For purposes of this authorization, medical information can include but not be limited to, information concerning illness, injury, treatment, rehabilitation, physicians’ names or referrals, and/or prognosis.
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Supplement/Medication Waiver I will not consume any nutritional supplement* other than those provided or having written approval from Athletic Department Sport Performance staff, Sports Dietitian, Coach McKeefery (Assistant AD/Head Strength & Conditioning Coach) or Steve Walz (Assistant AD/Director of Sports Medicine). I will notify Sports Medicine staff and Team Physicians of any current prescription medications I am presently taking prior to receiving any OTC* and Prescription medications* from Sports Medicine staff. *Nutritional supplement is any product (powder, pill, liquid, beverage, tablet, etc.) designed to supplement the diet which includes one or more of the following ingredients: vitamins, minerals, herbs, botanicals, amino acids, calorie boosters, constituents, extracts, or any combination of these ingredients. *OTC medications are medications that can be purchased over the counter from retailers such as drug stores, pharmacies, grocery stores and convenience stores. A prescription is not needed for these medications. Typical OTC medications include Tylenol, aspirin, ibuprofen, cough and cold formulas, and medications for allergies, constipation, diarrhea and nausea. *Prescription medications are generally more potent than those sold over-the-counter (OTC) and may have more serious side effects if inappropriately used. Therefore, these medications are only sold under a doctor’s direction.
All supplements must be approved by the three individuals listed above. Please list supplements/medication you are currently taking or have taken in the past 3 months:
1. 2. 3. 4. 5. 6. Print Name:__________________ Signature:___________________ Date:_________
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University of South Florida Liability Waiver
I, ___________________________, understand that there are risks in participating in the sport of _________________________. I am voluntarily assuming the responsibility for any such risks. Therefore, I consent to receive any emergency medical treatment deemed necessary by the Sports Medicine staff at the University of South Florida and agree that the Sports Medicine staff may terminate my participation at any time and for any reason. I waive and release the University of South Florida, the Board of Trustees (or any other entity designated by Florida law to manage, operate, and/or oversee the University of South Florida) and the officers, agents, employees, and any students acting on behalf of either the University of South Florida or the Board of Trustees, and the heirs, assigns or successors in interest of any and each of them from any and all Liability which may result or arise from either my athletics participation or any medical treatment I may receive. If any portion on this Release is held to be illegal, unenforceable, or in conflict with any laws of the State of Florida by any Court of competent jurisdiction, the remaining portions of this release shall not be affected.
_____________________________ Signature of Participant
________________________ Date
_____________________________ USF ID Number
________________________ Date of Birth
_____________________________ Signature of Parent/Guardian if Participant is under 18 years of age
________________________ Date
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Concussion Management Protocol Agreement
I, ___________________________, have been presented educational material regarding concussion injuries. I have read and understand this material and am aware of the concussion management protocol in place at the University of South Florida. I agree to report fully and honestly any and all concussion signs and/or symptoms I experience as a result of an injury, whether sustained during athletic participation or outside of athletic participation, to the University of South Florida Sports Medicine staff.
I understand that withholding
information regarding my symptoms puts me at risk for further injury and prevents the USF Sports Medicine staff from accurately assessing and managing my injury. I agree to abide by the USF Concussion Management Protocol and any treatment/management plans set forth by the USF Sports Medicine Department and/or USF Team Physicians.
_____________________________ Signature of Participant
________________________ Date
_____________________________ USF ID Number
________________________ Date of Birth
_____________________________ Signature of Parent/Guardian if Participant is under 18 years of age
________________________ Date
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