This emergency form collects contact and medical information for a player or cheerleader. It requests the name, address, parent/guardian contact details including phone numbers and text/email capabilities. It also asks for emergency contact information, medical insurance details, preferred hospital, physicians, dentist, allergies, current medications, and medical conditions. The form includes a permission to treat clause allowing a physician or dentist to treat the player/cheerleader in an emergency situation if the parent/guardian cannot be reached.

1. Bloomsburg Flag, Midget Football & Cheerleading
EMERGENCY FORM
Player/Cheerleader Name: ______________________________________
Address: __________________________________________________
Parent/Guardian: ____________________________________________
Phone: ____________________
Cell Phone: ________________
Work: ____________________
Text Capability:
YES or NO
Email Address: ______________________________________________
Emergency Contact: ____________________ Phone: _______________
Medical Insurance Name & Policy #: ______________________________
Preferred Hospital: __________________________________________
Family Physician/PCP: ___________________ Phone: _______________
Family Dentist: ________________________ Phone: _______________
Allergies: __________________________________________________
Current Medications: _________________________________________
Medical Condition (s): _________________________________________
Permission to Treat
I/We the parent(s)/guardian(s) of ___________________________, a member of Bloomsburg
Midget Football and Cheerleading, give permission for a physician or dentist to treat my/our
daughter and/or son because of an emergency situation caused by injury or illness while he/she was
participating in a football and/or cheerleading activity and I/we am/were not available to authorize
treatment.
Signature of Parent/Guardian: ____________________________________________
Date: ____________________