Medical Consent & Questionnaire

Consent to Medical Care
Athlete's Name (legal)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex/Gender*

MaleFemale
Consent to Medical Care

This is to certify that I give my consent to Panther City Rugby, its coaches and any medical service providers retained by them to provide and/or obtain medical care from an appropriately licensed healthcare provider, hospital, or clinic for any injury or illness that arises during my child’s participation in Rugby or other related activities.I understand that a person acting on behalf of Panther City Rugby will attempt to contact me or the "emergency contact" as soon as possible should an injury require medical care.I understand that I am financially liable for all costs related to the provision of care for the above named child.I certify that this form shall be in effect for twelve (12) months from the date of signature.
Signature of Custodial Parent/Guardian*

Clear
Name of Custodial Parent/Guardian*

First NameLast Name
Phone Number*

Area CodePhone Number
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation to Athlete*
Insurance Company*
Group Number
Policy (ID) Number
Policy Holder Name*
Medical Questionnaire

Please complete the following sections to help ensure appropriate care is given.
Medications
The athlete uses:

InhalerInsulinEpipen
The athlete recently had tetanus booster

YesNo
Prescription Medications (regularly taken)
Allergies to Medications
Medical Conditions

Has the athlete been diagnosed with and/or had any of the following prior to the current competitive season (in the last 48 months)?
Check All That Apply

Asthma / Shortness of Breath with ExerciseChest Pain / Tightness with ExerciseConvulsions / SeizuresDiabetesHigh Blood Pressure (Hypertension)DepressionFainting / Dizzy SpellsImpaired VisionImpaired HearingWeight Gain / Loss (significant)
Significant Injuries

Has the athlete been diagnosed with an injury to any of the following areas prior to the current competitive season (in the last 48 months)?
Check All That Apply

Head (Concussion)PelvisNeckHip / ThighChest / RibsKnee / Lower LegLower Back Shoulder / Upper ArmAnkle / FootElbow / Lower ArmAbdomen (Hernia)Wrist / HandOther
Please List Any Significant Surgeries with Month & Year
Acknowledgement
I understand that I should consult with my child’s physician before participating in a full contact sport such as Rugby. I further understand that I may need to meet with the team coach, athletic trainer or advising physician to discuss this questionnaire before my child is allowed to fully participate in all physical training and/or competitive activities.*
Initial
Should be Empty:

Consent to Medical Care

Medical Questionnaire