This document collects emergency contact and medical consent information for an athlete, including their name, address, phone numbers, email, parents' names and contact details, insurance information, physician details, allergies, medical conditions, and parental consent for any necessary medical care as a result of injury or illness during activities with the organization.

1. 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__________________ any necessary medical care as a result of any injury/illness.
(name)
This consent includes First Aid and transportation to/from health care providers.
_____________________
Date
______________________________________________
Father’s Signature
_____________________
Date
______________________________________________
Mother’s Signature
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