department of athletics policies & procedures - UNC Wilmington ...

Athlete’s Name
Male / Female
(First) (MI) (Last) (circle)
International Student: YES / NO (circle) Year of Eligibility: FR SO JR SR 5 th SR (circle) Sport
Date of Birth SS# UNCW ID# Email
INFORMATION FOR PARENT/GUARDIAN (PRIMARY INSURANCE)
Relationship to Student-Athlete (circle one) Father Mother Guardian Stepmother Stepfather Spouse Self
Name Date of Birth SS#
Address
City/State/Zip
Phone Hm Wk Cell Email
Insurance Company Phone #
Insurance Company Address
City/State/Zip
Is this insurance policy an: HMO Yes / No PPO Yes / No
**If yes please see reverse side
Effective Date of Policy
Expiration Date of Policy
Policy # Group # Authorization Phone #
Policy Limit(s) Policy Deductible Policy Co-Pay
List any special instructions or required authorizations needed prior to treatment
INFORMATION FOR PARENT/GUARDIAN (SECONDARY INSURANCE)
Relationship to Student-Athlete (circle one) Father Mother Guardian Stepmother Stepfather Spouse Self
Name Date of Birth SS#
Address
City/State/Zip
Phone Hm Wk Cell Email
Insurance Company Phone #
Insurance Company Address
City/State/Zip
295