Child's Name	____________________________________________________________
Team Name/Division	____________________________________________________________
Coach Name	____________________________________________________________
Presently on Medication Medical Problems Allergies	____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Last Tetanus Booster	____________________________________________________________
As parent/legal guardian of	____________________________________________________________ (Player's Name)
I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are medically necessary to preserve the life, limb or well-being of my dependent. This permission or consent is conditional upon the understanding that in the event of serious injury or illness or the need for surgery. _______________________________
(Coach/Assistant Coach/Team Manager)
will use all reasonable efforts to contact me. Failure in such efforts, however, should not prevent rendering necessary emergency treatment.
I have medical insurance	____________________________________________________________
	(Insurance Company and Policy Number)
Parent Name (Please Print)	____________________________________________________________
Parent/Guardian Signature	____________________________________________________________
Address	____________________________________________________________
	____________________________________________________________
Phone	____________________________________________________________
	This document will be shredded after the tournament