Student-Athlete Health Insurance Information
Daytona State College
(Please type or print)
Student-Athlete’s Name: ________________________________________________________ Sport: _________________________
Social Security Number: ____________________________________ Date of Birth: _________________ Gender: Male Female
Home Address: _______________________________________________________________________________________________
City __________________________________________________________ State ______________ Zip ______________________
Home phone # ( ) ________________________________ Athlete’s cell phone # ( ) ______________________________
Medications currently taking? _______________________________ Allergies/asthma______________________________________
Please copy the front and back of your insurance card and affix it below.
I hereby verify that the above information is correct and complete.
________________________________ ____________ ________________________________ ___________
Student-Athlete Signature Date Parent / Guardian Signature Date
MOTHER’S / GUARDIAN’S INFORMATION
Name: _________________________________________
SS#: _________________________________________
Date of Birth: __________________________________
Address: _________________________________________
_________________________________________________
Home Phone: ( ) ______________________________
Employer: ________________________________________
Employer Address: _________________________________
_________________________________________________
Work Phone: ( ) _______________________________
E-mail: __________________________________________
FATHER’S / GUARDIAN’S INFORMATION
Name: _________________________________________
SS#: _________________________________________
Date of Birth: __________________________________
Address: _________________________________________
_________________________________________________
Home Phone: ( ) ___________________________
Employer: ________________________________________
Employer Address: _________________________________
_________________________________________________
Work Phone: ( ) _______________________________
E-mail: __________________________________________
STUDENT-ATHLETE HEALTH INSURANCE INFORMATION
Does the Student-Athlete have health insurance? Yes No
Policy Holder Name: ____________________________________________________ Relationship: _______________________
Insurance Company: _______________________________________________________________________________________
Policy / ID #: ______________________________________________ Group #: _______________________________________
Insurance Company Claims Address: __________________________________________________________________________
City: _____________________________________________ State: ______ Zip: _________ Phone #: ( ) _______________
Type of policy: HMO PPO Point of Service Other: ______________________________________________________
Primary Care Physician: ______________________________________________________ Phone #: ( ) ________________
Is preauthorization necessary for any medical diagnostic services? Yes No Phone #: ( ) _______________
FRONT BACK
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