Health And Injury Information And Consent For Medical Treatment Form printable pdf download

Health and Injury Information and

Consent for Medical Treatment

This form is to be kept available for reference when a practice/competition takes place.

Update medical information when necessary.

Athlete’s Name______________________________

Age___ Grade___ Date of Birth_________________

Address________________________________________________________

Parent/Guardian Name(s) __________________________________________

Daytime Phone # (reach in emergency) _______________________________

Evening Phone # (reach in emergency) ______________________________

Preferred Hospital______________________________________________

Student currently taking medication? ______ If so, what?_______________________

Allergies to Medication________________________________

Student been prescribed inhaler or Epi-Pen?____________________________________

List any health

problems________________________________________________________________

(diabetes, asthma, seizures, depression, ADHD, heart problems, head injuries)

List all injuries resulting in loss of playing

time____________________________________________________________________

List any know allergies or other pertinent medical

information_____________________________________________________________

I (we) are aware that with the participation in sports comes the risk of injury. I (we)

understand that such a risk is inherent in play and practice for all sporting

activities.

**Date_______ Parent/Guardian’s Signature______________________________

Consent for Emergency Medical Treatment

Iowa law requires a parent’s, or legal guardian’s written consent before their son/daughter can

receive emergency treatment, unless, in the option of a physician, the treatment is necessary to

prevent death or serious injury.

As the parent(s) or legal guardian(s), of the child named above, I (we) authorize emergency

medical treatment or hospitalization that is necessary in the event of an accident or illness of my

(our) child. I (we) understand this written consent is given in advance of any specific diagnosis

or hospital care. This written authorization is granted only after a reasonable effort has been

make to contact me (us).

As the parent(s), or legal guardian(s), of the child named above, I (we) authorize medical

treatment and rehabilitation care that is necessary in the event of an injury to my (our) child.

Treatment may include heat, ice, and/or exercises to name a few.

**Date_________ Parent/Guardian’s Signature___________________________________

PLEASE NOTE: THIS FORM IS NOT COMPLETE

WITHOUT PARENT/GUARDIAN’S SIGNATURE.

Health And Injury Information And Consent For Medical Treatment Form