Sports Pack - Orange County Public Schools

SPORTS SCREENING PHYSICAL EXAMINATION / EXAMEN FÍSICO PARA
EVALUACIÓN DEPORTIVA
SCHOOL BOARD OF ORANGE COUNTY, Florida-
JUNTA ESCOLAR DEL CONDADO ORANGE, Florida
NOTICE TO PARENTS/LEGAL GUARDIAN
Orange County Public Schools strongly recommends that your child have a yearly comprehensive physical examination by your personal physician. The screening sport physicals,
given by volunteer doctors, are not intended to replace your child’s regular health maintenance. It is the responsibility of the parent/guardian of the athlete to make the choice for
medical care regarding your child. It is your clear understanding that participation in athletic activities creates a risk normally associated with such activities and that the risk increases as the sport becomes more vigorous and/or involves bodily contact.
NOTIFICACIÓN A LOS PADRES/ENCARGADOS LEGALES
Las Escuelas Públicas del Condado Orange recomienda enfáticamente que su hijo(a) tenga un examen físico completo anualmente con su médico personal. Las evaluaciones
físicas para deportes, realizadas por médicos voluntarios, no tienen la intención de reemplazar el cuidado regular de salud de su hijo(a). Es responsabilidad del padre/encargado
del atleta seleccionar el cuidado médico con respecto a su hijo(a). Ha de entenderse que la participación en actividades atléticas crea un riesgo normalmente asociado con tales
actividades y que el riesgo aumenta a medida que el deporte se vuelve más vigoroso y/o envuelva contacto corporal.
PARENTAL/LEGAL GUARDIAN & STUDENT NOTICE OF RESPONSIBILITY & CONSENT FOR PARTICIPATION
As a parent/legal guardian of a student who will be participating in any Orange County Public Schools athletic activity, your authorization to permit your child to participate requires
you understand and agreement to certain rules, responsibilities and regulations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Athletics is an extracurricular activity that will require a child maintain satisfactory grades and behavior in accordance with the OCPS/School Code of Conduct, and school/
team rules. Once a child is approved for sports activities you hereby give consent for participation.
You understand if a parent, guardian or student falsifies any signature or information on the sports screening physical examination, the student will be declared ineligible to
participate in any Orange County interscholastic activity for one full calendar year from disclosure date.
You further give permission for appropriate school staff and their designees to render medical treatment or authorize medical treatment by a hospital and/or doctor and
agree to hold the School Board and its employees harmless in the administration of such assistance.
You understand that this sports physical is valid for one calendar year.
You understand that if the student consults a medical physician concerning any injury received in an Orange County Public Schools-sponsored athletic practice of interscholastic sports contest, written medical approval must be obtained from that physician prior to the student’s further participation in activity. You understand that a written doctor’s note on the doctor’s stationary or prescription pad must be given to the athletic trainer or athletic director before that student will be allowed to resume activity.
You also consent for your child to be transported in connection with participation in athletic activities. You fully understand that this consent is given knowing that my child’s
participation in approved activities may, from time to time, require travel out of state as well as out of and within Orange County. You realize, and agree, that the travel may
be by private or publicly owned vehicles, bus, passenger car, on foot or various other means, as deemed appropriate and approved by the school principal.
Athletics require that your child and you commit to timely arrival and departure from the activity in accordance with the directive issued by the school principal or coach
designated by the school principal to direct said activities. Your failure to timely pick up your child may result in your child’s exclusion from the athletic activity.
You do authorize and give permission to the school principal, coaches, school representatives to release your child at the conclusion of the athletic activity. You do authorize and give permission to your child to individually determine his/her method and means of returning to your home upon conclusion of any daily athletic activity including but
not limited to his/her walking, riding with a friend, or any other means of transportation he/she chooses. If you have elected to give your child permission herein, you hereby
release the School Board of Orange County, Florida, its employees, agents, and assigns, from any and all liability or claims that my arise from or after your child leaving the
athletic activity.
You do grant permission to the school principal, coaches, school representatives the right to photograph and/or videotape the athlete and further to use name, face, likeness,
voice and appearance in connection with exhibitions, publicity, advertising, and promotional materials without reservation or limitation.
NOTIFICACIÓN A PADRES/ENCARGADOS LEGALES Y ESTUDIANTES DE RESPONSABILIDAD Y CONSENTIMIENTO PARA PARTICIPACIÓN
Como padre/encargado legal de un estudiante que estará participando en cualquier actividad atlética de las Escuelas Públicas del Condado Orange, su autorización de permitir
que su hijo(a) participe requiere que usted comprenda y acepte ciertas reglas, responsabilidades y regulaciones.
1. El atletismo es una actividad extracurricular que requiere que su hijo(a) mantenga calificaciones satisfactorias y un comportamiento acorde con el Código de Conducta
Estudiantil de OCPS, y las reglas del equipo escolar. Una vez que su hijo(a) sea aprobado(a) para actividades deportivas, usted por la presente, concede su permiso de
participación.
2. Usted comprende que si un padre, encargado o estudiante falsifica cualquier firma o información en el examen físico para evaluación deportiva, el estudiante será declarado
inelegible para participar en cualquier actividad interescolar del Condado Orange por el total de un año calendario desde la fecha de la revelación.
3. Usted comprende que este examen físico para evaluación deportiva es solo válido para el año escolar en curso. A fin deberá participar en atletismo interescolar
el año próximo, su hijo(a) deberá someterse a otro examen físico fechado después del último día del año escolar anterior.
4. Usted comprende que este examen fisico para evalucicion deportiva es solo valido por un ano.
5. Usted comprende que si el estudiante consulta con un médico con respecto a cualquier lesión recibida en una práctica atletica de un concurso deportivo interescolar
auspiciado por las Escuelas Publicas del Condado Orange, deberá obtenerse aprobación médica escrita de este médico antes de que el estudiante pueda continuar
participando en tal actividad. Usted comprende que una nota escrita del médico en papelería oficial del médico o en hoja de prescripciones deberá entregarse al
entrenador(a) o director(a) atlético antes de que dicho estudiante sea permitido regresar a la actividad.
6. Usted también acepta que su hijo(a) sea transportado en conexión con su participación en actividades atléticas. Usted comprende completamente que este consentimiento
se concede con el conocimiento de que la participación de su hijo(a) en las actividades aprobadas puede, de cuando en cuando, requerir viajar fuera del estado al igual
que dentro y fuera del Condado Orange. Usted está conciente y acepta que el viaje puede ser en vehículos privados o públi cos, autobuses, carros de pasajeros, a pie
o en otras formas variadas, según se considere apropiado y sea aprobado por el principal de la escuela.
7. El atletismo requiere que su hijo(a) y usted se comprometan a llegar y salir a tiempo de las actividades de acuerdo con las instrucciones emitida del principal escolar o
el/la entrenador(a) asignado(a) por el principal para dirigir dichas actividades. El no recoger a su hijo(a) a tiempo puede resultar en la eliminación de su hijo(a) de la
atividad atlética.
8. Usted autoriza y concede permiso para que el principal de la escuela, entrenadores, representantes escolares permitan la salida de su hijo(a) al finalizar la actividad
atlética. Usted autoriza y concede permiso para que su hijo(a) individualmente determine su método y medio de regresar al hogar al concluir cualquier actividad atlética diaria
incluyendo pero no limitándose a caminar, viajar con un amigo o cualquier otro medio de transportación que seleccione. Si usted ha decidido darle a su hijo(a)
permiso de esta manera, usted libra a la Junta Escolar del Condado Orange, sus empleados, agentes o asignados, de toda y cualquier responsabilidad o reclamación
que surja de o después de que su hijo(a) salga de la actividad atlética.
9. Usted autoriza y concede permiso para que el principal de la escuela, entrenadores, y/o representantes escolares tomen fotografía y/o videocinta del atleta. Además el
utilizar nombre, rostro, apariencia, voz y aparición relacionada con exhibiciones, publicidad y material de promoción sin reserva o limitaciones.
I hereby acknowledge and certify that I have read the sports screening document, that I understand and agree with its terms. I agree to be bound by its terms
and I have reviewed and explained the notice with my child.
Por la presente reconozco y certifico que he leído el documento de la evaluación deportiva, que comprendo y acepto sus términos. Acepto estar comprometido
con sus términos y he revisado y explicado esta notificación a mi hijo(a).
_________________________________________________
Signature of Parent/Legal Guardian
Firma del Padre/Encargado Legal
___________________________________________________
_______________
Print Name of Parent/Legal Guardian
Nombre del Padre/Encargado Legal
Date
Fecha
I hereby acknowledge and certify that I have read, understand and agree to be bound by the sports screening document.
Por la presente reconozco y certifico que he leído, comprendo y aceptado quedar comprometido por el documento de evaluación deportiva.
__________________________________________________ __________________________________________________
Signature of Athlete/Firma del Atlete
OC52—70520 REV. 04/11/02
Print Legal Name of Athlete/Nombre legal del Atleta
_____________________
Date / Fecha
*PHYSICIAN STAMP* / *SELLO DEL MEDICO*
*The following information is only necessary if there is no physician’s stamp:*
*La siguiente información no es necesaria a menos que no aparezca un sello del médico*
*Physician's Printed Name________________________________________ Office Telephone Number _____________________________
*Nombre escrito del médico
Número del teléfono de la Oficina
EL3
Florida High School Athletic Association
Consent and Release from Liability Certificate
Revised 05/11
(Page 1 of 2)
This completed form must be kept on file by the school. This form is valid for 365 calendar days from the date of the most recent signature.
Part 1. Student Acknowledgement and Release (to be signed by student at the bottom)
I have read the (condensed) FHSAA Eligibility Rules printed on the reverse side of this “Consent and Release Certificate” and know of no reason why I am not eligible
to represent my school in interscholastic athletic competition. If accepted as a representative, I agree to follow the rules of my school and FHSAA and to abide by their
decisions. I know that athletic participation is a privilege. I know of the risks involved in athletic participation, understand that serious injury, including the potential
for a concussion, and even death, is possible in such participation, and choose to accept such risks. I voluntarily accept any and all responsibility for my own safety and
welfare while participating in athletics, with full understanding of the risks involved. Should I be 18 years of age or older, or should I be emancipated from my parent(s)/
guardian(s), I hereby release and hold harmless my school, the schools against which it competes, the school district, the contest officials and FHSAA of any and all
responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against FHSAA because of any accident or
mishap involving my athletic participation. I hereby authorize the use or disclosure of my individually identifiable health information should treatment for illness or injury
become necessary. I hereby grant to FHSAA the right to review all records relevant to my athletic eligibility including, but not limited to, my records relating to enrollment
and attendance, academic standing, age, discipline, finances, residence and physical fitness. I hereby grant the released parties the right to photograph and/or videotape
me and further to use my name, face, likeness, voice and appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without
reservation or limitation. The released parties, however, are under no obligation to exercise said rights herein. I understand that the authorizations and rights granted herein
are voluntary and that I may revoke any or all of them at any time by submitting said revocation in writing to my school. By doing so, however, I understand that I will
no longer be eligible for participation in interscholastic athletics.
Part 2. Parental/Guardian Consent, Acknowledgement and Release (to be completed and signed by a parent(s)/guardian(s) at the
bottom; where divorced or separated, parent/guardian with legal custody must sign.)
A. I hereby give consent for my child/ward to participate in any FHSAA recognized or sanctioned sport except for the following sport(s):
__________________________________________________________________________________________________________________________________
List sport(s) exceptions here
B. I understand that participation may necessitate an early dismissal from classes.
C. I know of, and acknowledge that my child/ward knows of, the risks involved in interscholastic athletic participation, understand that serious injury, and even death,
is possible in such participation and choose to accept any and all responsibility for his/her safety and welfare while participating in athletics. With full understanding of
the risks involved, I release and hold harmless my child’s/ward’s school, the schools against which it competes, the school district, the contest officials and FHSAA of any
and all responsibility and liability for any injury or claim resulting from such athletic participation and agree to take no legal action against the FHSAA because of any accident or mishap involving the athletic participation of my child/ward. I authorize emergency medical treatment for my child/ward should the need arise for such treatment
while my child/ward is under the supervision of the school. I further hereby authorize the use or disclosure of my child’s/ward’s individually identifiable health information
should treatment for illness or injury become necessary. I consent to the disclosure, by my child’s/ward’s school, to the FHSAA, upon its request, of all records relevant
to his/her athletic eligibility including, but not limited to, his/her records relating to enrollment and attendance, academic standing, age, discipline, finances, residence and
physical fitness. I grant the released parties the right to photograph and/or videotape my child/ward and further to use said child’s/ward’s name, face, likeness, voice and
appearance in connection with exhibitions, publicity, advertising, promotional and commercial materials without reservation or limitation. The released parties, however,
are under no obligation to exercise said rights herein.
D. I am aware of the potential danger of concussions and/or head and neck injuries in interscholastic athletics. I also have knowledge about the risk of continuing to
participate once such an injury is sustained without proper medical clearance.
READ THIS FORM COMPLETELY AND CAREFULLY. YOU ARE AGREEING TO LET YOUR
MINOR CHILD ENGAGE IN A POTENTIALLY DANGEROUS ACTIVITY. YOU ARE AGREEING THAT, EVEN IF MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT
COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA USES REASONABLE CARE IN PROVIDING THIS ACTIVITY, THERE IS A CHANCE YOUR CHILD MAY
BE SERIOUSLY INJURED OR KILLED BY PARTICIPATING IN THIS ACTIVITY BECAUSE
THERE ARE CERTAIN DANGERS INHERENT IN THE ACTIVITY WHICH CANNOT BE AVOIDED OR ELIMINATED. BY SIGNING THIS FORM YOU ARE GIVING UP YOUR CHILD’S RIGHT
AND YOUR RIGHT TO RECOVER FROM MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS
AGAINST WHICH IT COMPETES, THE SCHOOL DISTRICT, THE CONTEST OFFICIALS
AND FHSAA IN A LAWSUIT FOR ANY PERSONAL INJURY, INCLUDING DEATH, TO YOUR
CHILD OR ANY PROPERTY DAMAGE THAT RESULTS FROM THE RISKS THAT ARE A NATURAL PART OF THE ACTIVITY. YOU HAVE THE RIGHT TO REFUSE TO SIGN THIS FORM,
AND MY CHILD’S/WARD’S SCHOOL, THE SCHOOLS AGAINST WHICH IT COMPETES, THE
SCHOOL DISTRICT, THE CONTEST OFFICIALS AND FHSAA HAS THE RIGHT TO REFUSE
TO LET YOUR CHILD PARTICIPATE IF YOU DO NOT SIGN THIS FORM.
D. I agree that in the event we/I pursue litigation seeking injunctive relief or other legal action impacting my child (individually) or my child’s team participation in
FHSAA state series contests, such action shall be filed in the Alachua County, Florida, Circuit Court.
E. I understand that the authorizations and rights granted herein are voluntary and that I may revoke any or all of them at any time by submitting said revocation in
writing to my school. By doing so, however, I understand that my child/ward will no longer be eligible for participation in interscholastic athletics.
F. Please check the appropriate box(es):
____ My child/ward is covered under our family health insurance plan, which has limits of not less than $25,000.
Company: ____________________________________________________________ Policy Number: ________________________________
____ My child/ward is covered by his/her school’s activities medical base insurance plan.
____ I have purchased supplemental football insurance through my child’s/ward’s school.
I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (Only one parent/guardian signature is required)
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
__________________________________________________
Name of Parent/Guardian (printed)
____________________________________________________
Signature of Parent/Guardian
_______/_______/____________
Date
__________________________________________________
Name of Student (printed)
____________________________________________________
Signature of Student –1–
_______/_______/____________
Date
I HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE (student must sign)
EL3
Florida High School Athletic Association
Consent and Release from Liability Certificate
Revised 05/11
(Page 2 of 2)
This completed form must be kept on file by the school
Attention Student and Parent(s)/Guardian(s)
Your school is a member of the Florida High School Athletic Association (FHSAA) and follows established rules. To be eligible to represent your
school in interscholastic athletics, in an FHSAA recognized sport (i.e. bowling, competitive cheerleading, girls flag football, lacrosse, boys volleyball,
water polo and girls weightlifting or sanctioned sport (i.e. baseball, basketball, cross country, tackle football, golf, soccer, fast-pitch softball, swimming
& diving, tennis, track & field, girls volleyball, boys weightlifting and wrestling), the student:
1.
Must be regularly enrolled and in regular attendance at your school. If the student is a home education student or attends a charter school, the
student must declare in writing his/her intention to participate in athletics to the school at which the student is permitted to participate. Home
education students must be approved by the FHSAA office prior to any participation. (FHSAA Bylaw 9.2)
2.
Must attend school within 10 days of the beginning of each semester to be eligible during that semester. (FHSAA Bylaw 9.2)
3.
Must maintain at least a cumulative 2.0 grade point average on a 4.0 unweighted scale prior to the semester in which the student wishes to participate. This GPA must include all courses taken since the student entered high school. A sixth, seventh or eighth grade student must have earned at
least a 2.0 grade point average on 4.0 unweighted scale the previous semester. (FHSAA Bylaw 9.4)
4.
Must not have graduated from any high school or its equivalent. (FHSAA Bylaw 9.4)
5.
Must participate at the school in which the student first enrolls (attends), or at which the student first takes part in an athletic practice, at the beginning of the school year. (FHSAA Bylaw 9.2)
6.
Must not transfer schools after the first day of fall practice or the first day of school, or otherwise the student cannot participate at the new school
for the remainder of the school year. (FHSAA Bylaw 9.3)
7.
Must not participate on a non-school team (i.e., AAU, American Legion, club setting, etc.) which is affiliated with a school or coached by a representative of a school other than the one the student attends, or has attended, and then attend that school, otherwise the student will be ineligible
there for one year. (FHSAA Bylaw 9.3)
8.
Must not transfer to a school that the student’s coach has relocated to within a year, otherwise the student will be ineligible there for one year.
(FHSAA Bylaw 9.3)
9.
Must not have enrolled in the ninth grade for the first time more than four school years ago. If the student is a sixth, seventh or eighth grade
student, the student must not participate if repeating that grade. (FHSAA Bylaw 9.5)
10. Must have signed permission to participate from the student’s parent(s)/guardian(s) on a form (EL3) provided the school. (Bylaw 9.8)
11. Must be less than 19 years 9 months old to participate in high school; 16 years 9 months old to participate in junior high school; and 15 years 9
months old to participate in middle school, otherwise the student becomes ineligible to participate at that level. (FHSAA Bylaw 9.6)
12. Must undergo a pre-participation physical evaluation and be certified as being physically fit for participation in interscholastic athletics (form
EL2). The physical evaluation is valid for 365 calendar days from the date that it was administered after which time the student must successfully
undergo another physical evaluation to continue his/her participation. (FHSAA Bylaw 9.7)
13. Must be an amateur. This means the student must not accept money, gift or donation for participating in a sport, or use a name other than his/her
own when participating. (FHSAA Bylaw 9.9)
14. Must not participate in an all-star contest in a sport prior to completing his/her high school eligibility in that sport. (FHSAA Policy 26)
15. Must display good sportsmanship and follow the rules of competition before, during and after every contest in which the student participates. If
not, the student may be suspended from participation for a period of time. (FHSAA Bylaw 7.1)
16. Must not provide false information to his/her school or to the FHSAA to gain eligibility. (FHSAA Bylaw 9.1)
17. Foreign exchange and international students must be approved by the FHSAA office prior to any participation. (FHSAA Policy 17)
If the student is declared or ruled ineligible due to one or more of the FHSAA rules and regulations, the student has the right to request that the school
file an appeal on behalf of the student. See the principal or athletic director for information regarding this process.
–2–
Orange County Public Schools Athletics
Verification of Residency Certificate
Student’s Name _______________________________ Date _____________
School ______________________________________ Grade ___________
I understand that the address used to enroll my child at this school, which I have listed below, is
our legal domicile.*
I understand that it is Orange County Public Schools policy that if a parent, guardian, or student
falsifies any information regarding residency or guardianship, the student-athlete will be
ineligible from representing any Orange County school for a period of one year from the date of
discovery.
Furthermore, if a falsification is discovered, the student-athlete will be reported to the Florida
High School Athletic Association (FHSAA) who may impose further sanctions concerning
athletic eligibility.
When a student-athlete is determined to be ineligible due to falsification of residency, he/she may
appeal the ruling to the Florida High School Athletic Association.
Address ___________________________________ City _______________ Zip ___________
Signature of Parent/Guardian _________________________________________
Print Name of Parent/Guardian __________________________________________
* Domicile is defined as the place where parents/guardians have their true and fixed, permanent
home and to which they have, whenever absent, the intention of returning. The parent/guardian’s
domicile determines the student’s domicile. Common indicators of domicile are home ownership
or in the absence of home ownership, a residential lease.
~------------SCHOOL BOARD OF ORANGE COlJNfY, Florida
BMRRtJENCY TREATMENT AUTHORIZATION CARD-Ene:lish
School:
Athletc's Legal Name:
Athlete's Date of Birth:
-
My <:hildis allergic to the followin medications:
Grade
-
-------.
-----------------
identify any serious injuries Qr illnesses your child Ita!.had:
--
Date0 flast tetanusshot: -
-
My child ':133lie followingallergies:
P".se
(Please Print)
____,_______
.
>
,______"
-
Alternatefamilymember/friendto contactin caseoi emergency:
Name:
Telephone Nurnber():
Primary Care Doctor Name:
Telephone Number:
You understand that the insurance offered by Orange County Public Schools is a secondary policy and will pay only after your p:o:rsonalinsurance pays, You Also
I1ndemand thut your child ;s only covere<! bv OCPS sport jnsurance during th FHSAA specified season.
Please wri!e "none" if you have no jX:rsonal insurance cn this athlete,
Primr Insurance Company, __
,.
__ t'olicyN'lmbe..:
__
-
Imoucancc:
CompanyAddrr.ss: .__
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Florida Statues (92.525) "Under penalties of perjury. I declare that I have read the foregoing and that the facts stated in it are true." I agree to be
bound by its terms and I have reviewed and explained the notice with my child,
Signature of Parent/Legal Guardian
Telc.i'oone (H)
Stte
Date
'Print Name ofParentlLegal Guardian
.
Other
Telephone (W)
Arldress:
State:
City:
.
Zip:
-, ,
'
12515
PLEASE FILL OUT BOTH COPIES
---
EMERGFI'lCY TREATMENT AUfHORIZA.fION
CARD-EJ>.&!lli1
SCHOOL BOARD OF ORANGE' COUNTY. Florida
.\thlcte's Lega! Name:
School:
Ath!ete's Date of Birth:
Date oflast tetanus shot:
(Please Print)
Grade
My child is allergic to t/1e following medications:
My child has the following allergies:
Please identify any serious injuries or illnesses your child has had:
Alternate family member/friend to contact in case of emergency:
Name'
Telephone Number(s):
Primary Care Doctor Name:
Telephone Number:
You understand that the insurance offered by Orange County Public Schools is a secondary policy and will pay only after your personal illsurance pays. YOIIAlso
Ul1deamd that YOllrrhild :s on:y covered by OCPS sport insurance during the FHSAA specified season.
Plwe write "none" if you haveno p"[SOnal insurance on this athlete.
.
Prim8l) InsuranceCompany:
Policy Number:
InsuranceCompanyAddress:
,'You understand if a parent, guardian or student falsifies any signature or informalion on Ihe emergency medical treatment carli, the slurlent will be declared ineligible
to participate in any Orange County interscholastic activity for one full calendar year from disclosure date. You further give your permission for appropriate school
staff and their designees to render medical treatment or authorize medical treatment by a hospital and/or doctor and agree to hold Ihe School Board and its employees
harmless in the administralion of such assistance. I herby acknowledge and certify that I have read the emergency medical documenl, thai I understand and agree
with its terms Florida Statues (92.525) "Under penalties of perjury, I declare that I have read the foregoing and Ihat the facts staled in it are Irue." I agree 10 be
bound by its terms and I have reviewed and explained the notice with my child.
.
.
Signature ofParentlLegal Guardian
,
Telephone(H)
Dale
Other
Telephone (W)
_.
Stteet Address:
City:
---
Prinl Name ofParentlLegal Guardian
State:
Zip:
12515
,