Emergency Information
EMERGENCY INFORMATION & CONSENT
(ONE FOR EACH ATHLETE)
Address:_________________________________________________________________________
Home Phone:(____)__________Work Phone:(____)__________Email________________________
Father's Name:____________________________________________________________________
Address:_________________________________________________________________________
Employer:________________________________________________________________________
Home Phone:(____)__________Work Phone:(____)__________Email________________________
Mother's Name:____________________________________________________________________
Address:_________________________________________________________________________
Employer:________________________________________________________________________
Home Phone:(____)__________Work Phone:(____)__________Email________________________
Family Medical Insurance:
Carrier:__________________________________ Group:__________________________________
Policy #:_________________________________ Group#:_________________________________
Family Physician's Name:____________________________________________________________
Physician's Address:________________________________________________________________
Physician's Phone:(_____)___________________ Email: __________________________________
Allergies (list):_____________________________________________________________________
Serious Medical Conditions (list):______________________________________________________
I/we hereby grant consent to any and all health care providers designated by:___________________ (organization's name) to provide my child__________________ (name) any necessary medical care as a result of any injury/illness.
This consent includes First Aid and transportation to/from health care providers.
_____________________ ______________________________________________
Date Father's Signature
_____________________ ______________________________________________
Date Mother's Signature