Emergency Medical Form And Release - 2-4-1 Sports Women'S Lacrosse League - West Hardfort
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1______ Camper
_______ Staff
’
2-4-1 S
W
L
PORTS
OMEN
S
ACROSSE LEAGUE
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MERGENCY
EDICAL
ORM AND
ELEASE
Name: __________________________________________
Date of Birth: ___________________
Address:___________________________ Town: ________________________ State: ____ Zip:________
Home Phone: __________________________ Parent Cell:___________________________________
In case of emergency, attempt to contact the following people :
Name
Relationship
Phone Number(s)
1. ____________________________
____________________
____________________________
2. ____________________________
____________________
____________________________
Doctor: ______________________________
Phone: _____________________
Hospital Preference: _____________________
Please list ALL medical conditions which may in any way effect or limit the athlete’s ability to participate, or
which responding medical personnel may need to know in the event of an emergency. (i.e. – asthma or other
respiratory conditions, history of seizures, dizziness, fainting, heart problems, all previous injuries or surgeries,
etc.) ______________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list ALL medications being taken by the athlete, and the medical condition for which she/he takes them:
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list ALL allergies, including medicines, foods, insects and other environmental causes, and the symptoms
they cause: ________________________________________________________________________________
__________________________________________________________________________________________
Please list ALL medications which will be provided for use at camp (i.e.- inhaler, epi-pen, etc.): ____________
_________________________________________________________________________________________
** Please bring clear written instructions for the use of any medications, and give them to our First Aid
Director on the first day of camp.
Primary Insurance Carrier: _______________________________Policy Number: _______________________
A
F
E
M
T
/
UTHORIZATION
OR
MERGENCY
EDICAL
REATMENT AND USE OF PHOTOS
VIDEO
I give my permission for x________________________________ to participate in The 2-4-1 Sports Programs at Conard High School.
I realize that athletic activities, such as those taking place at 2-4-1 Sports involve the potential for injury which is inherent in all sports.
I acknowledge that even with the best coaching and supervision, proper use of equipment, and strict observance of rules, injuries are
still a possibility. On rare occasions, such injuries can be so severe as to result in total disability, paralysis, or even death. I also give
permission for use of my child’s image at any/all 2-4-1 Sports Programs in photographs or video to be used for future
promotional/marketing materials for 2-4-1 Sports. I hereby authorize you to take whatever action you deem necessary to provide for
the health and welfare of my child, x _____________________________________________, in case of an emergency.
x ________________________________________ x ________________________________________ x _____________
Athlete or Parent’s or Guardian’s Signature
Athlete 0r Parent or Guardian Name (Please Print)
Date
to:
2-4-1 Sports, LLC, 249 Auburn Road, West Hartford, CT 06119
Please return this form
or scan to:
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