1. Are there any injuries requiring medical attention?
   Yes
   No
2. Are there any past surgeries or scheduled surgeries?
   Yes
   No
3. Is there any history of concussions and/or head injuries?
   Yes
   No
4. Is the participant currently under the care of a medical practitioner?
   Yes
   No
5. Is the participant currently taking any medications?
   Yes
   No
6. Does the participant have any allergies (penicillin, bee stings, etc)?
   Yes
   No
7. Does the participant have asthma/require the use of an inhaler?
   Yes
   No
8. Is the participant diabetic/require medication for diabetes?
   Yes
   No
9. Does the participant carry sickle cell trait/suffer from sickle cell disease?
   Yes
   No
10. Does/has the participant have/had seizures?
    Yes
    No
11. Does the participant wear glasses or contact lenses?
    Yes
    No
12. Does the participant wear a brace or other medical support device?
    Yes
    No
13. Does the participant have any other physical limitations or medical conditions?
    Yes
    No

I hereby grant my child permission to play football / cheer with the Apple Valley Timberwolves. I agree not to hold the organization’s officers, directors, coaches, or any other benefactors of this league liable for any injury, result of such injury received by my child during practice sessions, games, or in the process of transportation to or from any league activities. Furthermore, I hereby acknowledge that it is my responsibility to inform my child’s coach or organization official if there is any change in the medical condition of my child. I certify that my child has recently been examined by a qualified physician and is medically able to participate.

Payment will be due at the first practice