FBC Liability Waiver

Player First Name

Player Last Name

Class Of

Parent / Guardian First Name

Parent / Guardian Last Name

Signature Date

Phone Number:

Parent Email

Medical Condition:

Is the FBC participant covered by health insurance

Yes

No

Policy Holder First Name

Policy Holder Last Name

Policy Holder Date of Birth

Address

Address Line 1

City

State

Zip Code

Relation to Participant

Employers Name

Employers Phone

Insurance Company Name

Insurance Company Phone

Member #

Group #

Subscription Form

First Name

Last Name