Emergency Contact Form

Name of Participant / Player (Please submit a different form for each participant)*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship to Player*
Physician
Phone Number
Please enter a valid phone number.
Allergies (including medications, bee stings, foods, etc.)*
Please list any medications you (or participant) is currently taking
Medical Insurance Company
Policy Number (Phone#)
The undersigned authorizes appropriate medical care as deemed necessary by emergency personnel, a physician or the medical facility providing treatment. As Parent or Legal Guardian of the above-named minor, I ask that every effort be made to contact me at the time of the accident or illness without detriment of postponing medical treatment. I have read and understood this entire release form and agree to it. I have read and understood this entire release form and agree to it.
Legal Signature (Guardian or Player Over 18)*

Clear
Date*

MonthDayYear
Date
Should be Empty: