ONE FOR EACH ATHLETE

FULL NAME

NICKNAME OF ATHLETE

ADDRESS

PHONE NUMBER

IS THIS A LANDLINE OR A MOBILE PHONE?
MOBILELANDLINE

ALLERGIES (list)

SERIOUS MEDICAL CONDITIONS (describe)

I/we hereby grant consent to any and all health care providers designated by:_________________(organization’s name) to provide me,________________(name), any necessary medical care as a result of any injury/illness.
This consent includes first aid and transportation to/from health care providers.

EMERGENCY CONTACT INFORMATION

NAME OF EMERGENCY CONTACT

PHONE NUMBER

EMAIL

SIGNATURE OF PARTICIPANT
Please sign below

DATE SIGNED