Document ID: f5c5c5c6d1c2df2d1b591515af6e48e2aa58dd47
March 20, 2019
Signed On : https://m14hoops.com

Medical Release Form - Steve Seaney


Date: 03/20/2019
Signer Name: Steve Seaney
Signer Email: sseaney@gmail.com

Player Name: Steve Seaney

Insurance Provider: BCBS IL
Primary Insurance Holder: Lisa M Seaney
Account Group No: 7348000

Emergency Contact: Steve Seaney
Phone Number: (630) 962-9327
Relationship: Father

Address:
434 Linden Str

Glen Ellyn, IL 60137
United States

Signed by Steve Seaney
Signed on:March 20, 2019

Signature Certificate
Document name: Medical Release Form - Steve Seaney
Unique Document ID: f5c5c5c6d1c2df2d1b591515af6e48e2aa58dd47
Steve Seaney
Party ID: 0375565a-7ac7-48ac-9fb6-6f00a387749a
IP Address: 64.53.137.213
Security Level: E-mail
Digital Signature:
Multi-Factor
Digital Fingerprint Checksum
302eb2b08cf391b2b58db53b3d2a4c62
Timestamp Audit
2019-03-20 15:45:21 CDTMedical Release Form - Steve Seaney Uploaded by Matt Miller - medicalform@m14hoops.com IP 71.2.154.132
2019-03-20 15:45:23 CDTDocument viewed by Steve Seaney - sseaney@gmail.com IP 64.53.137.213
2019-03-20 15:45:38 CDTDocument signed by Steve Seaney - sseaney@gmail.com IP 64.53.137.213
2019-03-20 15:45:38 CDTThe document has been signed by all parties and is now closed.
2019-03-20 23:22:50 CDTDocument viewed by Steve Seaney - sseaney@gmail.com IP 34.228.55.57