Emergency Information
(ONE FOR EACH ATHLETE)
Athlete’s Name :________________________________ Nickname: __________________
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.
___________________________________________________________________
Father’s signature and date
___________________________________________________________________
Mother’s signature and date