MHEA Eagles Basketball Information Form - One Form Per Student

MHEA Membership No.:

Last Name: First Name: Middle Name:

Preferred Name (Nickname):

Address:

City: State: Zip:

Home Phone: Cell Phone:

Email Address:

Grade: Date of Birth: Year of Graduation

Father Alternate Phone:

Mother Alternate Phone:

Insurance Information
Since the malpractice question has come to the forefront, many hospitals and doctors will not treat a child without parent’s consent (unless a-matter of life or death). It is requested that you complete the information below so that if your child requires a visit to the hospital while under supervision of the Eagles Basketball Program this will allow the hospital to treat the injury.

Insurance Company: Ins. Co. Phone:

Employee Name:

Policy #: Group Number:

Family Physician : Physician Phone:

Name of person authorized to act for parent(s) in an emergency:

Emergency Contact Name: Relationship:

Home Phone: Alternate Phone:

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©2005 Memphis-Area Home Education Association