PARENTS: FILL THIS OUT! VERY IMPORTANT!

MEDICAL CONDITIONS
& Emergency Treatment Form


Does your child have any dangerous medical conditions that I should know about (such as asthma?)

If so, list them below. Also, please sign to authorize emergency treatment.

1. Child's Name:
_______________________________________________________________________________
2.
How can you be reached in an emergency?
Tel. No:
_______________________________________________________________________________
Cellular:
_______________________________________________________________________________
Pager:
_______________________________________________________________________________

3.
Dangerous medical conditions (e.g., asthma):
________________________________________________________
   
___________________________________________________________________________________________

___________________________________________________________________________________________
4.
Is there anything a doctor should know (e.g., drug allergies):
____________________________________________
   
___________________________________________________________________________________________

___________________________________________________________________________________________
5. In a medical emergency, I authorize the coach and related personnel (such as assistants or parents of other team members) to take my child to the closest hospital for treatment.

Sign here: ____________________________________________________________________________________
(Parent or Guardian)
Date: __________________________________


Copyright SoccerHelp.com. This form may be copied, revised and used as long as this is left on the bottom of the form.



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