Wisconsin 2013 Lakers Medical Release Form
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WISCONSIN LAKERS MEDICAL RELEASE FORM AND LIABILITY WAIVER
To be completed legibly and signed by Participant AND Parent/Guardian.

Participant Name______________________________________________ Current Grade ___________________
Street Address__________________________________ City____________________________ Zip___________
Phone___________________________Email_____________________________________________
Birth Date_____________ School ______________________________ School District_________________________

Emergency Contact Information (PLEASE PRINT):
Primary Contact Name: ____________________________ Phone Number: _________________________
Secondary Contact Name: ____________________________ Phone Number: _________________________

Participant Signature:

Date ________________________
(regardless of age):

To Be Read and Signed by Parent / Guardian:
I attest Participant is in good physical condition and has no disability, impairment or ailment that prevents them from
engaging in exerc