MEDICAL INFORAMTION

(PLEASE PRINT)

 

TEAM NAME: _______________________________________________

 

PLAYER NAME: _____________________________________________

 

MY INSURANCE COMPANY: ___________________________________

 

My FAMILY DOCTOR: _________________________________________

 

DOCTOR’S PHONE NUMBER: __________________________________

 

MY FAMILY DENTIST: __________________________________________

 

DENTIST PHONE NUMBER: ______________________________________

 

Should an injury occur, please contact: ____________________________

 

His/her phone number is: ______________________________________

 

If there is a choice, the hospital that I prefer to be taken to is: ____________________________________________________

 

Hospital phone number is: ______________________________________

 

PLEASE LIST OUT ANY ALLERGIES, MEDICATION ALLERGIES AND MEDICAL CONDITIONS: ____________________________________________________________________________________

 

 

PLAYERS SIGNATURE: ____________________     DATE: ______________

 

PARENT/GUARDIAN SIGNATURE: ___________________DATE: _________

 

COACHES MUST VERIFY THAT ABOVE INFORMATION IS CORRECT TO THE BEST OF THEIR ABILITY

 

COACH OR COORDINATOR SIGNATURE: ___________________________

 

DATE: _______________

 

COACHES MUST CARRY A COPY OF THIS FORM TO ALL GAMES