PLAYER NAME:

ADDRESS:

City, State, Zip:

PARENT NAMES:

HOME PHONE:

WORK PHONE:

CELL PHONE:

EMERGENCY CONTACT SHOULD PARENTS BE UNAVAILABLE

NAME:

PHONE:

ALLERGIES TO MEDICATIONS:

MEDICAL INSURANCE NUMBER:

MEDICAL INSURANCE COMPANY:

(PLEASE ATTACH A COPY OF THE INSURANCE CARD if there was a change or it is not on file))

KNOWN MEDICAL PROBLEMS OR CONDITIONS (include current medications):

DATE OF LAST TETANUS BOOSTER:

(PRINT PARENT NAME) I______________

GIVE CONSENT FOR THE ABOVE NAMED PLAYER TO RECEIVE MEDICAL TREATMENT IN MY ABSENCE. CONSENT FOR MEDICAL TREATMENT MAY BE OBTAINED FROM THE INDIVIDUALS LISTED BELOW.

Lloydlee Heite  Director (302-228-9992), or STINGERS EVENT SUPERVISOR

PARENT SIGNATURE:

DATE: