Emergency Contact Form

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

First NameLast Name

Date of Birth*

Date

Emergency Contact*

First NameLast Name

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Player*

Physician

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

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)*

Date*

Date