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Emergency Medical Authorization Form

Purpose: to enable parent(s)/guardian(s) to authorize the provision of emergency treatment for athletes who become ill or injured while under club supervision when parent(s)/guardian(s) cannot be reached.

Parent Info

Parent 1 Name(Required)

Parent 1 Phone(Required)

Parent 2 Name

Parent 2 Phone

Child 1 Name(Required)

Child 2 Name

Child 3 Name

Preferred Physician Name(Required)

Preferred Hospital(Required)

Authorization

Grant Consent

I DO provide consent.

In the event reasonable attempts to contact parent/guardian at the above phone numbers have been unsuccessful, I hereby give my consent for:

1: The administration of any treatment deemed necessary by Preferred Physician or another licensed Physician or Dentist if Physician is not available.

2: The transfer of the athlete to Preferred Hospital or any other hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concur on the necessity for such surgery before the performance of such surgery.

Facts concerning the athletes’ medical history include allergies, medications being taken, and any physical impairments to which a physician should be alerted.

Refusal of Consent

I DO NOT provide consent

I do not give consent for emergency action to be taken. Should illness or injury requiring emergency
treatment occur, I wish the authorities to take no action.

Name

This field is for validation purposes and should be left unchanged.

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Emergency Medical Authorization Form

Parent Info

Authorization

Title