Participant’s Name________________________________________Birthdate_________
Street Address_______________________City__________________Zip_________
Father’s Name____________Home#___________Wk#__________Cell#__________
Mother’s Name____________Home#____________Wk#__________Cell#__________
In an emergency contact the following:
Name_________________Home#____________ Wk#__________Cell#________
Allergies_____________________________________________________________
Medical conditions_____________________________________________________
Physician__________________________ Business Phone#_________________
Medical/Insurance Co._________________________Phone#_____________________
Policy Holder’s name__________________________Policy#_____________________
This Authorization for emergency medical treatment must be completed before a
player begins participation. Treatment for injury will be based in information
provided herein.
Parent/Guardian Signature____________________________________Date:_______
Note:
Please attach copy of Insurance card, front and back to expedite medical
treatment.