Emergency Medical Authorization

PLAYER NAME ____________________________________________

 

ADDRESS __________________________________________________

 

TELEPHONE _______________________________________________

 

SCHOOL ______________________________________________ GRADE _______________

 

Purpose: To enable parents and guardians to authorize the provision of emergency treatment
for children who become ill or injured while under coaches authority, when parents or guardians
cannot be reached.

Part I or II must be completed
PART I - TO GRANT CONSENT

In the event reasonable attempts to contact me at _____________________ (phone number) or

___________________ (other parent or guardian) at ___________________ (phone number) have been

unsuccessful, I hereby give my consent for: (1) The administration of any treatment deemed
necessary by Dr. ________________ (preferred physician) or Dr. _______________ (preferred dentist).,
or in the event the designated preferred practitioner is not available, by another licensed physician
or dentist; and (2) the transfer of the child to _________________ (preferred hospital) or any hospital
reasonably accessible.
______________________________________________________________________________
 

This authorization does not cover major surgery unless the medical opinions of two other licensed
physicians or dentists, concurring on the necessity for such surgery, are obtained prior to the
performance of such surgery.

 

Facts concerning the child's medical history including allergies, medications being taken, and any
physical impairments to which a physician should be alerted: ___________________________
____________________________________________________________________________
____________________________________________________________________________

Date _____________  Signature of Parent or Guardian ___________________________________

Do not complete Part II if you completed Part I
PART II - REFUSAL TO CONSENT

I do not give my consent for emergency medical treatment of my child. In the event of illness
or injury requiring emergency treatment, I wish the coach to take no action or to: __________
___________________________________________________________________________
___________________________________________________________________________

Date _____________  Signature of Parent or Guardian ___________________________________

Address _____________________________________________________________________________

Medical Insurance Company ___________________________________ Policy # ___________________