Parental Instructions Concerning Medical Treatment:
Wrestler's Name: ______________________ Date of Birth: _________
Parent/Guardian Name: ___________________________________________
Address: ________________________________________________________
Telephone Numbers: Home: _______________ Work: _______________ Cell:________________
Please indicate another person to
contact in the event of an accident and we are unable to reach you.
________________________________________ Telephone: ____________
Insurance Company: ______________________________________________
Policy Number: __________________________________________________
Is your son presently on medication?
____________________________
If yes, please list medication(s): ______________________________
Drug Sensitivities: _____________________________________________
Other Allergies: ________________________________________________
List here any physical impairments, hospitalization, injury, blackouts during
competition, athletic participation restrictions, surgery or serious medical
illness this athlete has had. ____________________________________________________________
_________________________________________________________________
_________________________________________________________________
Please read the alternative statements below and sign under the one that you
choose. DO NOT SIGN MORE THAN ONE!
1. If my child needs medical attention, it is my wish that I be contacted before any medical procedures are done on my child, unless immediate treatment is necessary to save my child's life or to prevent permanent injury.
SIGNATURE OF PARENT/GUARDIAN: ___________________________DATE: _____________________
2. If my child needs medical treatment while participating, it is my wish that the treatment be begun while efforts are being made to contact me. So that treatment is not delayed, I consent to any medical procedures that the physician believes needed, on the understanding that efforts will continue to be made to contact me. I accept responsibility for all cost related to such treatment.
SIGNATURE OF PARENT/GUARDIAN: ___________________________DATE: _____________________
Coach's Name: _______________________
Club Name: __________________________