Child Medical Consent Form

Child Medical Consent Form

Team Tribe Wrestling Club
Parental Information
Parent/Guardian #1*

First NameLast Name
Phone Number*
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Parent/Guardian #2

First NameLast Name
Phone Number
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Child*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Consenting Party
Team Tribe Wrestling Club

St. John Bosco High School

13640 Bellflower Blvd, Bellflower, CA 90706

tribewrestling@gmail.com
Child's Medical Information
Blood Type
Food Allergies (Please Specify)*
Drug Allergies (Please Specify)*
Name of Pediatrician*
Phone Number of Pediatrician*
Insurance*
Policy Number/Medical ID Number*
I/We, {parentguardian1} and/or {nameOf23}, hereby declare that I am/We are the parent(s)/legal guardian of {nameOf}, who was born on the {dateOf}. I/We do hereby consent to my child's medical care and the administration determined by a physician to be necessary for the welfare of my/our child while said child is under the care of Team Tribe Wrestling Club located at St. John Bosco High School 13640 Bellflower Blvd, Bellflower, CA 90706.
Signature of Parent/Guardian #1*

Clear
Date signed*

MonthDayYear
Date
Should be Empty: