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Emergency Information

Emergency Information

EMERGENCY INFORMATION & CONSENT
(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