Fall Sports Physicals

Patient's First Name *

Patient's Last Name *

Patient's DOB *

Relationship To Patient *

Contact Number *

Email *

Are you an existing patient? *

Yes

No

Additional Comments

As the individual and on behalf of minor, personal representatives and my heirs, I hereby voluntarily agree to release, waive, forever discharge, hold harmless, defend and indemnify PAK and their agents, officers, boards, volunteers and employees from any and all liability and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my participation in activities related to the event. I also hereby grant permission for PAK to publish images of activities and of me for the purpose of promoting PAK. On behalf of the participant and minor, individually, the undersigned parent(s) and/or legal guardian(s) for the minor participant executes this Waiver and Release. If, despite this release, the participant makes a claim against PAK, the parent(s) and/or legal guardian(s) will hold PAK and or it’s employees harmless for any injury, claim, monies, sanctions. I grant the permission freely without reservation.

Confirmation *

I Agree

Request An Appointment Below!

PIAA requires your child to get a Fall Sports Physical AFTER May 1st

1212 S. Abington Rd. | Clarks Summit, PA 18411 | Phone: 570-585-2615

1081 Oak Street Suite 1 | Pittston, PA 18640 | Phone: 570-602-PAKP

451 3rd Ave Ste.1 | Kingston, PA 18704 | Phone: 570-288-6543

239 S Mountain Blvd Ste.600 | Mountaintop, PA 18707 | Phone: 570-715-7020