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PARENTS: FILL THIS OUT! VERY IMPORTANT!

MEDICAL CONDITIONS
& Emergency Treatment Form

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: ____________________________________________________________________________________
(Parent or Guardian)
Date: __________________________________


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