SCNV Medical/Emergency Treatment Release

Medical/Emergency Treatment Release

Skating Club of Northern Virginia
I hereby authorize any physician and/or any member of the medical staff of any hospital or emergency treatment center to render medical treatment, which is his/her judgement may be deemed necessary in the care of:
Full Name (Self, Parent/Guardian) *

First Name Last Name
Skater's Full Name *

First Name Last Name
Skater's Gender *
Skater's Phone Number (Primary) *

Area Code Phone Number
Skater's Date of Birth *

Month Day Year
Skater's Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Skater's Phone Number (Secondary)

Area Code Phone Number
Skater's Email Address *
Skater's Parent/Guardian Full Name (Primary) *

First Name Last Name
Medical Professional Contact Information

If none available, type NONE
Skater's Parent/Guardian Email Address (Primary) *
example@example.com
Skater's Parent/Guardian Full Name (Secondary)

First Name Last Name
Skater's Parent/Guardian Email Address (Secondary)
example@example.com
Skater Parent/Guardian's Phone Number (Primary) *

Area Code Phone Number
Skater Parent/Guardian's Phone Number (Secondary)

Area Code Phone Number
Please provide two alternate contacts in case the primary/secondary contacts are unavailable during an emergency:
Skater's 1st Alternate Contact Full Name

First Name Last Name
Skater's 2nd Alternate Contact Full Name

First Name Last Name
Skater's 1st Alternate Contact's Phone Number

Area Code Phone Number
Skater's 2nd Alternate Contact's Phone Number

Area Code Phone Number
Skater's Medical Contact Full Name *
Medical Contact Office Address *
Medical Contact Office Phone Number *

Area Code Phone Number
Health Insurance Phone Number *

Area Code Phone Number
Health Insurance Organization Name *
Health Insurance Organization Policy Number
Health Insurance Subscriber Relationship to Skater *

Self Mother Father Guardian Other
Skater Medical History

To be provided to medical professional staff in the event of emergency
Allergies
Past Medical History
Current Medications (if any)
E-Signature: *
I hereby certify that all the information provided is correct to the best of my knowledge.
Should be Empty:

Medical/Emergency Treatment Release

Medical Professional Contact Information

Skater Medical History