TOURNAMENT TEAMS
MEDICAL CONSENT

Participant’s Name______________________________________Birthdate___________

Street Address___________________________City__________________Zip_________

Father’s Name____________Home#___________Wk#__________Cell#____________

Mother’s Name____________Home#____________Wk#__________Cell#___________

In an emergency when parent/guardian cannot be reached, 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.