Emergency Medical Treatment Consent And Information Template
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1Emergency Medical Treatment, Consent and Information
The following information will be used in the event that a parent / legal guardian is not available. The purpose of this
information is to provide a quick reference for medical personnel should the need arise. Please fill out this form
completely. If a particular question is not applicable write "none", n/a, or other appropriate comment otherwise none will
be assumed. If additional space is needed, please use the back of this form. All information disclosed here will be
treated as confidential. It will be the responsibility of the parent/legal guardian to notify the participants coach and
league/event officials if any information needs to be added, deleted, changed, or updated in any way.
ATHLETE INFORMATION
Nick Name:
Phone: (
)
Athlete's Name:
Address:
City:
State:
Zip:
PARENT OR GUARDIAN INFORMATION
Father's Name:
Address:
City:
State:
Zip:
Hm Phone: (
)
Daytime Phone: (
)
Email:
Employer:
PARENT OR GUARDIAN INFORMATION
Mother's Name:
Address:
City:
State:
Zip:
Hm Phone: (
)
Daytime Phone: (
)
Email:
Employer:
PARENT OR GUARDIAN INFORMATION
Guardian's Name:
Address:
City:
State:
Zip:
Hm Phone: (
)
Daytime Phone: (
)
Email:
Employer:
FAMILY MEDICAL INSURANCE
Carrier:
Group:
Policy #:
Group #:
Policy Holder Name:
Family Physician's Name:
Dr's Address:
City:
State:
Zip:
Phone: (
)
Fax: (
)
Email:
EMERGENCY MEDICAL INFORMATION
Preferred Hospital(s):
EMERGENCY CONTACT:
Phone: (
)
Relationship:
Please list any medical conditions (allergies, asthma, etc.) And medications being taken by the participant named
above. Please list any other information you may deem relevant, and helpful to emergency medical personnel: (please
note if no information is given and the words "none" or "n/a" is not filled in then, "none" will be assumed.
Allergies:
Medical Conditions:
Other:
*I Hereby my signature grant permission for my child/ward to participate in any and all, __________________________
(Association name) and, American Youth Football, Inc / American Youth Cheer dba, program(s) sanctioned event(s), be
they official or un official, including but not limited to, athletic, social and/or fundraising activities. I further hereby
consent to any and all health care providers, authorize any first aid, emergency treatment, including but not limited to
transportation to and from health care facilities and/or any medical professional to provide treatment, order injections,
hospitalize, give anesthesia or perform surgery. I understand that this authorization is given prior to any need for
medical care, but given to avoid unnecessary delay in emergency treatment which the attendant and/or medical
professional may deem advisable in the exercise of best judgment. I presume a reasonable attempt was made to
contact me.
*Print Parent/Legal Guardian Name
*Signature Parent/Legal Guardian
*Date
The original Emergency Medical Treatment, Consent and Information form should travel with the coach and a copy should be kept at the
administrative office of the sports organization. Due to privacy concerns, completed forms should be stored in a secure location with access
restricted to those on a need to know basis for the purpose of medical care.
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