• Mon, 05/07 | Baseball vs. Methodist W, 3-2 (Final - 10 innings) BX | RC | LS
  • Sun, 05/06 | Women's Track and Field CAC Championship (Outdoor) 6th (TBA) R | RC | PH
  • Sun, 05/06 | Men's Track & Field CAC Championship (Outdoor) T-5th (TBA) R | RC | PH
  • Tue, 05/01 | Baseball vs. Gwynedd-Mercy W, 6-0 (Final) BX | RC | PH
  • Sun, 04/29 | Baseball at Shenandoah W, 15-6 (Final) BX | RC | PH
 

Athlete’s Name

First:
Last:   

Social Security #

DOB

 

Sport(s)

Year in School

 

Date

 

 

Home Address

Street   
Street2
City
State
Zip Code

Phone #

                                               

Family Physician

 

Phone #

 

 

By checking here I state that my son/daughter is NOT COVERED under my group insurance (if NOT COVERED, complete Name/Contact number and proceed to the Acknowledgement portion of the form)

 

Father’s Name

 

Social Security #

 

Home Address

Street
City  State  Zip Code

                                               

Employer Name

Phone#

 

 

Employer Address

Street
 City  State  Zip

                                               

Home Telephone

 

Work Telephone

Medical insurance Co

Phone #

           

 

Address

Street
City  State  Zip

                                              

Group #

 

Policy #

 

 

Is the above policy a HMO? PPO? Or managed care network?

 

 

Does the insurance require second opinions prior to surgery or pre-authorization for services?

Yes  No

 


 

 

Mother’s Name

Social Security #

 

 

Home Address

Street   
Street2
City  State  Zip Code

                                               

Employer Name

Phone#

 

Employer Address

Street
City   State  Zip Code

                                                Street                                   City                        State                     Zip Code

Home Telephone

Work Telephone

 

Medical insurance Co

 

Phone #

 
           

 

Address

Street
City  State  Zip Code

                                                Street                                   City                        State                     Zip Code

Group #

 

Policy #

 

Is the above policy a HMO? PPO? Or managed care network?

 

Does the insurance require second opinions prior to surgery or pre-authorization for services?

Yes  No

 

I certify that the answers provided are true, complete and correct to the best of my knowledge.  A photocopy of this authorization shall be considered as effective and valid as the original

 

 

 

Name of Student-Athlete

Date

 

 

 

Signature of parent

 

Date