Medical Consent

Please fill in the Medical Consent form below

Child Information

Child Name*

First Last

Birth DateDate*

Date of last tetanus booster*

Allergies to drugs or foods

Medications

List any restrictions

Parent / Guardian Information

Name*

First Last

Phone*

Email*

Name

First Last

Phone

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency and Medical Contacts

Emergency contact (friend or relative)*

First Last

Phone*

Family physician*

First Last

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Authorization to Treat a Minor

I (we), the undersigned parent or legal guardian of the child listed above.
In case of emergency, I hereby give permission to the physician selected by the club staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child. As parent or legal guardian of the applicant, I am in favor of him/her attending club functions and accept the conditions named. The health history stated is correct so far as I know, and the person herein described has permission to engage in all prescribed club activities except as noted. In addition, I have read and understand the Emergency Authorization Statement and give my full consent to the terms found therein. Permission for photocopying of this form is granted.

By typing your full name in the field below, you affirm that you are signing this document electronically. You acknowledge and agree that your typed name constitutes your legal signature and has the same force and effect as a handwritten signature. By signing, you confirm that you have read, understood, and agreed to the terms set forth in this document.

Child Full Legal Name*

Parent/Guardian Full Legal Name*

Date*