Supplement
11-2
MEDICAL TREATMENT CONSENT FORM
I hereby give permission for any and all medical attention necessary to be administered to my child in the event of an accident, injury, sickness, etc., under the direction of the persons listed below until such time as I may be contacted.
My child's name is, (Name: First, Last) ____________________________________.
This release is effective for the time
during which my child is participating in the program for the
20____ to 20____ seasons, including traveling
to or from competition. I also hereby assume the responsibility for payment of
any such treatment.
Parents Names
__________________________________________________________________
Home Address (Street/City/State/Zip) ______________________________________________________________
Insurance
Company ______________________________________________________________
Policy
Number ___________________________________________________________________
Family
Physician: _______________________________________________________________
Physician’s
Address: _____________________________________________________________
Physician’s
Phone: _____________________________
In case I
cannot be reached, either of the following people is designated:
Coach's
Name______________________________ Phone____________________
Assistant Coach's Name______________________
Phone____________________
Signature of Parent or Guardian:
__________________________________________
Printed name
of parent/guardian __________________________________________
Subscribed and sworn before me this____ day of ________ 20____
Signature of
notary public or other witness: _____________________________
Printed name if witness:
_____________________________
11-14
PACE
(Adapted
from the “Program for Athletic Coach’s Education” or PACE)
(Rev.
Nov. 2004 CJI)