| Department of Intercollegiate Athletics | |
| Sonoma State University | |
| Rohnert Park, CA 94928 | |
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SPORTS CAMPS AND CLINICS
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SPONSORED BY THE SSU ATHLETICS DEPARTMENT
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Emergency and Insurance Information
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| Name of Participant: _________________________________________ Birth Date: ______________________ | |
| Home Address: _________________________________________ City:___________________ Zip:_________ | |
| Phone (day): __________________________________ Phone (evening):________________________________ | |
| Insurance Information | |
Is participant covered by an individual or family policy? Yes_____ No_____ |
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Name of insurance carrier: _________________________________________________________ |
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Name of family physician: ___________________________________ Phone: _________________ |
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| The following information is required if the participant is a minor: | |
| In the event that I cannot be contacted in case of emergency, I hereby authorize the director or staff of the sports camp or clinic at Sonoma State University to contact and/or release my child to either of the two persons named: | |
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Name _____________________________________ Address (home) _____________________________ City ______________________ Zip _____________ Phone _____________________________________ Relationship ________________________________ |
Name _____________________________________ Address (home) _____________________________ City ______________________ Zip _____________ Phone _____________________________________ Relationship ________________________________ |
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Name of Parent or Legal Guardian: _______________________________________________________________ Signature: __________________________________________________________ Date: ___________________ |
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