Athletic Profile

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Student Info:

First Name

Last Name

Grade Level

Date of Birth

Gender

Male

Female

Address line 1

Address line 2

City

State

Zip

Student Phone

Student Email

Coach's Emergency Card

First Name

Last Name

Home Phone

Work Phone

Mobile Phone

Role

Unknown

Mother

Father

Guardian

First Name

Last Name

Home Phone

Work Phone

Mobile Phone

Role

Unknown

Mother

Father

Guardian

First Name

Last Name

Home Phone

Mobile Phone

Role

First Name

Last Name

Home Phone

Mobile Phone

Role

Medical Info:

Medical Concerns

Current Medications

Allergies

Chronic Illnesses

Previous medical condition requiring hospitalization, therapy, or frequent medical treatment

Clinic Name

Clinic Phone

Doctor Name

Doctor Phone

Preferred Hospital

Dentist Name

Dentist Phone

Insurance Carrier

Policy

Hibbing Public Schools
800 East 21st Street
Hibbing, MN 55746

Office Phone:	(218) 208-0848
Superintendent of Schools:	Mr. Richard Aldrich

Hibbing Public Schools,

Celebrating Success!

Hibbing Public Schools

800 East 21st Street • Hibbing, MN • 55746

Athletic Profile

Address:

Parent / Guardian 1

Parent / Guardian 2

Emergency Contact 1

Emergency Contact 2

Providers

Insurance

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