Greenville Magic Basketball

HEALTH HISTORY

Personal Information

Participant's Name ______________________________________________________ Date of Birth  ____ /____ /____ Age ______

Parent or Guardian ___________________________________________________________________________________________

Address ________________________________________________City ____________________State ________Zip ____________

Evening Phone ____________________________________                  Day Phone ______________________________________

Parent/Guardian ______________________________  Emergency Contact _____________________________________________

Contact Phone ______________________________________________

Insurance Information

We do do not have family health coverage.
Insured by: ________________________________ Policy No. ________________________ Subscriber No.___________________

We do do not have family dental coverage.
Insured by: ________________________________ Policy No. ________________________ Subscriber No.___________________

Health History

MISCELLANEOUS			DISEASES			ALLERGIES
	Ear Infections	__________		Mononucleosis	__________		Hay Fever	__________
	Rheumatic Fever	__________		Chicken Pox	__________		Poison Ivy	__________
	Heart Disease	__________		Measles	__________		Insect Stings	__________
	Heart Defects	__________		German Measles	__________		Penicillin	__________
	Convulsions	__________		Mumps	__________		Other Drugs	__________
	Diabetes	__________		Asthma	__________	Name of Drugs		__________
	Hypertension	__________		Bleeding Disorder	__________		____________________
	Sleepwalking	__________		Clotting Disorder	__________		____________________


IMMUNIZATIONS			DATES OF OPERATIONS OR SERIOUS INJURIES			CURRENT MEDICATIONS
	MMR (Measles, Mumps, Rubella)	__________	________________		__________	________________		__________
	DTP Series	__________	________________		__________	________________		__________
	Tetanus	__________	________________		__________	________________		__________

Medical Contacts

Family Dentist: __________________________________________________________________ Phone No.___________________

Family Physician: ________________________________________________________________ Phone No.___________________

Restrictions

	None
	Special situations or activities in which the athlete may not be able to participate: ___________________________________
____________________________________________________________________________________

Consent to Medical Care

I ____________________________ verify that this health questionnaire is correct to the best of my knowledge, and that _____________________________ the person herein described, has my permission to engage in all prescribed activities, except as noted by me on this health form.
I further verify that I am the parent and legal guardian of the child registered on this form, and hereby authorize the Greenville Magic and its delegated leaders and directors to consent to any medical and hospital care to be rendered to said minor upon the advice of a licensed physician. It is understood that if time and circumstances reasonably permit, Greenville Magic will endeavor, but is not required, to communicate with me prior to such treatment. The undersigned further agrees that the Greenville Magic and its designated leaders and directors are not legally or financially liable for any claim rising from any consent given in good faith in connection with such diagnosis or advised treatment. This authorization and consent to treatment of this minor is given to the Greenville Magic in conjunction with any authorized event.

______________________________	______________________________
Signature of Parent/Guardian and Print Name	Date

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