Emergency Contact Form

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Emergency Contact Form
Lil Mavs Volleyball Program
Athlete Name: ______________________________________ Grade: ____
Age: ____
Insurance Company: _________________________________
Any medical history we need to be aware of? YES
NO
If Yes, please explain:
_________________________________________________________________________________________________
Any Medication or inhaler she needs to have with her at all times? YES
NO
If yes, please list the name of it and how often she needs to take it:
_________________________________________________________________________________________________
If in case of an emergency, who should we contact:
Main Contact:
Name: ______________________________________ Relationship: ____________________
Telephone number: ____________________________
nd
2
Contact if we cannot get a hold of the Main contact:
Name: ______________________________________ Relationship: ____________________
Telephone number: _____________________________
Please feel free to list any other names who we can contact if the above do not respond with their telephone
number:
_________________________________________________________________________________________________
Lil Mavs Volleyball wants to make sure you know we want to keep your daughter’s life safe and keep all parties
informed of any emergencies. The information you provide is for the program and head coach to have with them
at all events and practices so that we can contact the above people in case of an emergency. The information
will not be shared with any person outside of the program. Please sign below if you agree that all the information
given above is true and that you give Lil Mavs Volleyball staff full permission to use the information if necessary
throughout the season. Thank you!
Athlete signature: __________________________________________
Parent signature: ___________________________________________
Date: _______________________

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