Usa Hockey Consent To Treat/medical History Form

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Usa Hockey
Consent to treat/medical History form
This is to certify that on this date, I __________________________________________, as parent or
guardian of __________________________________________, (athlete participant), or for myself as an
adult participant, give my consent to US Hockey and its medical representative to obtain medical
care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury
that could arise from participation in US Hockey sanctioned events.
If said participant is covered by any insurance company, please complete the following:
Insurance Company: ___________________________________________________________
Policy Number: _______________________________________________________________
parent/Guardian/adult participant signature: _____________________________
date: __________
Excess accident insurance up to $25,000, subject to deductibles, exclusions and certain limitations,
is provided to all US Hockey registered team participants. For further details visit or
contact US Hockey at (719) 576-US H.
emerGenCy ContaCt
Name: ___________________________________________________
Phone: _____________________
ddress: _________________________________________________________________________________
Physician’s Name: ________________________________________
Phone: _____________________
Hospital of Choice: ________________________________________________________________________
Completion of mediCal History information Below is optional
mediCal History
If the answer to any of the following questions is yes, please describe the problem and its implications
for proper first aid treatment on the back of this form.
Head Injury
sthma
llergies _________________
(concussion, skull fracture)
High blood pressure
Diabetes
Fainting spells
Kidney problems
Other ____________________
Convulsions/epilepsy
Hernia
_________________________
Neck or back injury
Heart murmur
_________________________
Have you had (or do you currently have) any of the following?
Have you had a recent tetanus booster?
Yes
No If yes, when? _________________________
Are you currently taking any medications?
Yes
No If yes, please list all medications on back.
Has a doctor placed any restrictions on your activity?
Yes
No If yes, please explain on back.
3C rev 2/09

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