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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.

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.