WAIVER FORM — USAO SOCCER CHICKASHA, OK

Camper Name

First Name

Last Name

Parents Name(s)

Home Address (Street - City - State - Zip)

Phone # for Emergency Purposes

List all allergies you want the staff to be aware of

List any and all medications the staff need to be aware of

List any and all medical conditions the staff need to be aware of

Physicians Name

Insurance Provider

Insurance Policy #