Emergency Medical Authorization

Sep 3, 2015

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This is the 2nd part of the registration process.
If you haven’t already, register and pay for membership at: surfsss.surfsignup.com, register, and pay.

Students Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Surf Team*
Emergency Medical Authorization
Emergency Contact*
Phone*
HEALTH INSURANCE?
- YES, I HAVE INSURANCE
- NO, I DO NOT HAVE INSURANCE
Insurance Carrier*
Group #*
Subscriber Name*
ID #*
Family Doctor*
Doctor's Phone
Date of Last Tetanus Shot
Allergies
Medical Condition(s) to be aware of
Name
This field is for validation purposes and should be left unchanged.