Usa Wrestling Medical Packet (Page 2 of 5) in pdf

Usa Wrestling Medical Packet Page 2

USA WRESTLING

PARENT'S INSTRUCTIONS ON MEDICAL TREATMENT

PLEASE PRINT IN CAPITAL LETTERS

Wrestler's Name

Date of Birth

Parent/Guardian Name

Relationship

Address

Home Phone

Work Phone

Please indicate another person to call it an accident occurs and we are unable to reach you:

Name

Phone No.

Insurance Company

Policy No.

Family Doctor

Phone No.

Is your child presently on medication?

If yes, please list medication (s):

Drug Sensitivities

Other Allergies

Date of your child's last complete physical examination by a medical doctor

If this is more than one year ago, please complete the accompanying medical history questionnaire.

Please read the alternative statements below and sign under the one that you choose. Sign only one!

1. If my child needs medical attention, it is my wish that I am contracted before any medical procedures are

taken on my child, unless immediate treatment is necessary to save my child's life or to prevent permanent

injury.

Parent/Guardian Signature

Date Signed

2. If my child needs medical treatment while participating, it is my wish that the treatment is started while

efforts are being made to contact me.

So that treatment is not delayed, I consent to any medical

procedures that the physician believes are needed, on the understanding that efforts to contact me will

continue to be made. I accept responsibility for all costs related to such treatment.

Parent/Guardian Signature

Date Signed

Wrestler's USA Wrestling Card No.

Name of Club

Coach's Name

Phone Number

Usa Wrestling Medical Packet Page 2