Does your child have any dangerous medical conditions that
I should know about (such as asthma?)
If so, list them below. Also, please sign to authorize emergency treatment.
| 1. |
Child's Name:
|
_______________________________________________________________________________
|
2.
|
How can you be reached in an emergency?
|
Tel. No:
|
_______________________________________________________________________________
|
Cellular:
|
_______________________________________________________________________________
|
Pager:
|
_______________________________________________________________________________
|
3.
|
Dangerous medical conditions (e.g., asthma):
|
________________________________________________________
|
|
___________________________________________________________________________________________
|
|
___________________________________________________________________________________________
|
4.
|
Is there anything a doctor should know (e.g.,
drug allergies):
|
____________________________________________
|
|
___________________________________________________________________________________________
|
|
___________________________________________________________________________________________
|
| 5. |
In a medical emergency, I authorize the coach and
related personnel (such as assistants or parents of other team members) to
take my child to the closest hospital for treatment.
|
Sign here: ____________________________________________________________________________________
Date: __________________________________
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