WINNETKA HOCKEY CLUB
Authorization For Emergency Medical Treatment
This form will be kept on file with
the team manager
One player per form |
| |
| Player's Last Name: |
Player's First Name: |
|
Birth Date: |
| Address:
City: State:
Zip: |
| Mother's Name: |
Home Phone: |
| |
Business Phone: |
| |
Cell Phone: |
| Father's Name: |
Business Phone: |
| |
Cell Phone: |
| |
|
| Other contacts and phone number(s)
for emergencies when parents cannot be reached: |
| Name:
Relationship:
Phone: |
| Name:
Relationship:
Phone: |
| |
| Player's Physician:
Physician's Phone: |
| Physician's Address:
|
|
Known allergies, medical conditions or problems,
prior injuries: |
|
| May the team coach, assistant
coach, manager, or designee apply first aid?:
Yes
No |
| |
|
The undersigned grant(s) permission to coach,
assistant coach, manager or their designated representative to
authorize emergency medical treatment considered necessary by
qualified medical personnel. This authorization is for WHC-sponsored
events when the parent, legal guardian or emergency contact is not
present or immediately available. It is understood that every
reasonable effort will be made to contact a parent immediately
should any emergency occur.
I have
read, understand, and agree to the above AUTHORIZATION FOR
MEDICAL TREATMENT. I also declare that I am the above
child/children's legal parent or guardian. Please check box if
you agree. |