Survey - WFCA: Consent & Liability Form 2021 - Children's Hospital of Wisconsin

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Question - Required - Player first name:

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Question - Required - Player middle name:

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Question - Required - Player last name:

Question - Not Required - Player Cell Phone:

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Question - Required - Player email (not a school email address):

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Question - Required - Team:

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Question - Required - Player date of birth:

Month

Day

Year

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Question - Required - Player mailing address:

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Question - Required - City:

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Question - Required - State:

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Question - Required - County:

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Question - Required - Zip code:

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Question - Required - Parent or guardian's name:

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Question - Required - Primary phone number for parent/guardian:

Question - Not Required - Secondary phone number:

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Question - Required - Mailing address:

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Question - Required - City:

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Question - Required - Zip code:

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Question - Required - Second contact name:

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Question - Required - Primary phone number for contact:

Question - Not Required - Secondary phone number:

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Question - Required - Mailing address:

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Question - Required - City:

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Question - Required - Zip code:

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Question - Required - Name of player's insurance company:

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Question - Required - Insurance company phone number:

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Question - Required - Policy holder's name:

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Question - Required - Policy holder's date of birth:

Month

Day

Year

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Question - Required - Insurance company's address:

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Question - Required - City:

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Question - Required - State:

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Question - Required - Zip code:

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Question - Required - Name of policy holder's employer:

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Question - Required - Policy number:

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Question - Required - Group number:

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Question - Required - Is the player allergic to any medications?

Question - Not Required - If yes, please list here:

Question - Not Required - Please list all medications player is taking:

Question - Not Required - List any other allergies (bee stings, dust, food allergies, etc):

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - What kind of reaction does the player have to those allergies?

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - If the player suffers from asthma, diabetes, epilepsy or any other medical conditions, please list below:

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Question - Required - Has the player ever suffered a concussion?

Question - Not Required - If yes, list number of times and dates of each:

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Question - Required - Does the player wear contacts?

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Question - Required - Name of family physician:

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Question - Required - Phone number for family physician:

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Question - Required - I understand that football is a physically demanding sport and participation can result in personal injury. I hereby release and hold harmless the WFCA, its affiliates, coaches, medical staff, employees, officers and directors; sponsors of the WFCA All-Star Game; and the WFCA officials from any liability associated with participation in this event, including but not limited to fall, contact with other participants, the effects of weather, traffic, and other reasonable risks arising out of my participating in the WFCA All-Star Game. I certify that I have no medical ailments that would jeopardize my participation in the WFCA All-Star Game. I further provide that this hold harmless agreement applies to my heirs, executors, and assignees. I authorize the medical staff covering the duration of WFCA All-Star Game to arrange for any medical attention, which they deem necessary should injury occur, including but not limited to dispensing over the counter medication.

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Question - Required - Parent/Guardian Initials (By initialing below, I acknowledge that I have read, understand, and agree to all of the above waivers and consents and that all medical information is correct to the best of my knowledge):

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Question - Required - Players initials (By initialing below, I acknowledge that I have read, understand, and agree to all of the above waivers and consents and that all medical information is correct to the best of my knowledge):

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Question - Required - I agree to play in this year's WFCA All-Star Charity Football Game.