Sport:  _________________________________________ Grade: __________________

Name: _____________________________________________ Age: ________________

Address: _____________________________________ Home Phone: _______________
                _____________________________________

Parent/Guardian: 

  Father: ________________________________________________________

  Mother: _______________________________________________________

Work Phone Numbers: 

  Father: _____________________________ Hours can be contacted: ______________

  Mother: _____________________________ Hours can be contacted: ______________

                        In an emergency when the Parent/Guardian cannot be contacted

Notify: __________________________________________ Phone: _________________

Family Doctor: ____________________________________ Phone: ________________

Preferred Hospital: ________________________________

The team physician, trainer and coach may apply first aid treatment until medical aid and/or ambulance service arrives  YES ___  NO ___.  We give our consent for coaches, trainers and team physicians to use their own judgment in securing medical aid and ambulance service in the event of an emergency  YES ____ NO ____

_________                              ___________________________________________
Date                                                                             Parent/Guardian Signature

Please Check All That Apply:

Asthma: ____                                                   Allergies:

Epilepsy: ____                                                  Medication: ______

Diabetes: ____                                                 Pollen: ______

Kidney Failure: ____                                         Bee Sting: _____

Heart Problem: _____                                       Other: ______________________

If allergic to medication, please state the medication:

___________________________________________________

If you are taking medication at this time please state the medication:

___________________________________________________ ____________________________________________