Pwsi Emergency Contact And Medical Release Form
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1PWSI EMERGENCY CONTACT AND MEDICAL RELEASE FORM
Player’s Name_________________________
Player’s Date of Birth: ____/____/____
Date of Last Tetanus Booster: ____/____/____
Month Day Year
Month Day Year
Mother’s/Guardian Name_______________________________Father’s/Guardian Name___________________________Emergency Contact_____________________________
Address:_______________________________________
Address:_____________________________________
Address:_____________________________________
City/StateZip:_____________________________ _____
City/State/Zip:_________________________________
City/State/Zip_________________________________
Occupation: ____________________________________
Occupation: __________________________________
Phone: (H)(____)_____-______(W)(____)_____-_____
Phone: (H)(____)_____-______(W)(____)_____-_____
Phone: (H)(____)_____-______(W)(____)_____-_____
Cell: (_____)_______-________
Cell: (_____)______-_______
Cell: (_____)______-______
E-Mail______________________________________________E-Mail___________________________________________E-Mail_______________________________________
Known Allergies of this player, including any and all allergies to medice:______________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Any other medical problems which should be noted: _____________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Family Physician: _________________________________ Phone: (____)______-________ Insurance Carrier:_____________________Policy Number: _____________________
As the parent/legal guardian of ______________________________________, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of
Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. If said care requires
the above mentioned player to be admitted to any hospital or medical facility for diagnosis and treatment, I hereby in my absence request and authorize physicians, dentists and
staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses affiliated with such facilities to perform any diagnostic procedures,
treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the result of examinations or treatment. I
authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above mentioned player.
Parent/Guardian Signature___________________________________________________
Date_________________________________________________________
COACH: This form should be filled out by a parent/guardian for each player on your team. This form should be maintained by the coach and in his/her possession at all practices and games.
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