Emergency Care Permission
Emergency Care Permission Form
(This form is to be completed by each team
member at the beginning of the season and kept in the possession of the coach)
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Athlete's Name:
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As parent or guardian of the above named athlete,
I hereby authorize _______________________________________________
to provide care, including authority for medical transportation, in the
event of injury or illness. I also authorize qualified medical
personnel to provide emergency medical care in the event of an emergency.
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Parent/Guardian:
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Address:
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City:
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State:
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Zip:
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Daytime phone:
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Evening phone:
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Other authorized person to contact in
emergency:
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Relationship to athlete:
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Daytime phone:
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Evening phone:
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Family doctor:
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Doctor's phone:
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Athlete's allergies, chronic illness,
medications taken, or other medical conditions:
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Signed:
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Date: |