Academic Information:  SAT-M _____  SAT-V ____ Reading  ____ PSAT-M ____ PSAT-V ____

Coaches Name _____________________________ Coaches Phone ______________

 Parent Consent and Medical Information
(Players cannot participate unless they have medical insurance).
(Players cannot participate unless this section has been completed and signed by the parent or guardian). I understand that the Shootout and the host school do not carry medical or accident insurance for the participants, and I here by certify that my child is covered by personal insurance or is included in a policy which I have in place. I authorize routine medical care for my child by the Shootout trainer. I further authorize any treatment considered routine to be referred to a local physician or to an emergency room at my expense. I further authorize and provide my consent and permission for my child to participate in this event.

Insurance Company ____________________ Policy _____________ Group # ________

Name of Policy Holder _____________________________ Home Phone __________

Signature of parent/guardian _________________________ Cell phone _____________