Medical Insurance Information. If you have no insurance, you must contact our office to assist you in getting medical coverage for the duration of the program. Students must have insurance in order to participate in NAPCA programs.
Medical Insurance Information. Medical Insurer: Policy Number: Primary Doctor’s Name: Phone #: Name: Address: Phone #: Parent/Guardian Signature Date CONSENT TO PHOTOGRAPH, FILM, OR AN INDIVIDUAL FOR NON-PROFIT USE I hereby provide consent to the Seattle Indian Health Board (SIHB), its representatives, employees, and its affiliated program partners, to participate in interviews, provide quotes, and/or use my image in photographs or videos for educational, public service, or health awareness purposes. I also grant them the right to edit, use, and xxxxx said products for non-profit purposes, including use in print, on the internet, and in all other forms of media. I also hereby release the SIHB and its agents and employees from all claims, demands, and liabilities whatsoever in connection with the above. I have read and understand the above: Parent/Guardian Signature Date (If under 18) Youth Participant Signature Date Parent/Guardian: Relationship to youth: Home Phone: Work/Message Phone: Second to Contact: Relationship to youth: Home Phone: Work/Message Phone: I understand that the information given on this form will be used to contact members and relatives for emergencies only. Seattle Indian Health Board is providing transportation from our location (000 00xx Xxx X.) to Taholah, Washington. Will one of the above contacts be responsible for transporting the youth participant to the designated drop-off and pick-up location at Seattle Indian Health Board? Yes, please specify who: If NO, please provide contact information: Name: Relationship to youth: Home Phone: Work/Message phone: Parent/Guardian Signature Date 1 Pair - comfortable, sturdy walking shoes with good tread 1 Pair - sandals or flip flops 5 Pair - socks 5 Pair - underwear 5 Pair - shorts or pants 5 Shirts (T-shirts) 1 Backpack
Medical Insurance Information. Please complete the following information pertaining to the individual whose name appears on the insurance card AND provide a copy of the FRONT and BACK of the INSURANCE CARD. Adult Carrying Insurance: Relationship to Cadet: Adult’s Date of Birth: / / Adult’s Social Security # Adult’s Employer: Employer's Telephone #: ( ) - _ Employer's Address: Name of Insurance Company: Telephone #: ( ) - _ Address: City: State: Zip code: Policy #: Certificate #: Group #: CADET LAST NAME: CADET FIRST NAME: CADET DATE OF BIRTH: / / CADET SOCIAL SECURITY NUMBER: CADET IDENTIFYING MARKS (Scars, Birthmarks, Tattoos, etc.): Primary Nationality Gender Height Weight Hair Color Eye Color CUSTODIAL PARENT(S)/GUARDIAN (S)*: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUSINESS PHONE: SECOND PARENT(S)/GUARDIAN(S)*: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUSINESS PHONE: SECONDARY CONTACT: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: BUSINESS PHONE: RELATION TO CADET:
Medical Insurance Information. The Brandywine Classic will provide a certified athletic trainer on-site to respond to anyone in need of medical attention. Accordingly, I hereby authorize the Brandywine Classic directors to act for me according to their best judgment in case of any situation requiring medical attention. I understand that every participating student is required to have health insurance coverage that provides an appropriate level of benefits befitting a participant in a contact sport including lacrosse. Participating students cannot be registered without providing the following complete health insurance information as follows:
Medical Insurance Information. This camper is covered by family medical/hospital insurance. ❑ Yes ❑ No Insurance company Policy number Subscriber _ Insurance company phone number ( )
