Arkansas Silverbacks

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Arkansas Silverback Tryout Form

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

Email:

Birthdate:

Positions:

Work Schedule:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

WAIVER INFORMATION

The Arkansas Silverbacks are providing a direct insurance contact for players to enroll in accident insurance. It is the player's decision to accept or decline the insurance coverage. This form will remain on file as long as the player is under contract with the Arkansas Silverbacks. If the player enrolls or declines to enroll in provided insurance coverage and becomes injured, the aforementioned player will not hold the Arkansas Silverbacks liable for the injury nor any medical costs that the player will incur.

* Waiver of accident insurance:

I/we agree with the above *

* indicates required fields

IMPORTANT: Online Payment with credit cards is not active for this form

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Arkansas Silverback Tryout Form