This is to certify that on this date, I
(print name of parent/guardian)________________________________________________,
as parent or guardian of
(print name of athlete)_______________________________________________________,
give my consent to Vianney Club Hockey, Inc., Mid-States Club Hockey Association, USA Hockey and their representative, to obtain medical care from any physician, hospital, or clinic for the above named athlete, for any injury that could arise from participation in Vianney Club Hockey, Inc., Mid-States Club Hockey Association, or USA Hockey events. In so doing, I release and absolve the Vianney West Club Hockey, Inc., Mid-States Club Hockey Association, and their club hockey members, officers, and directors from responsibility for any and all consequences occurring there from.
Signed (parent/guardian)__________________________________________________________________________
Date_____________________
Relationship to Athlete ___________________________________________________________________________
PRINT the following Information:
Full Name of Athlete ____________________________________________________________________________
Address of Athlete ______________________________________________________________________________
Athlete�s Birth Date ______________________________ Athlete�s Social Security No._________________________
Mother�s Name & Address _______________________________________________________________________
Father�s Name & Address ________________________________________________________________________
Name of Health Insurance Carrier ___________________________________________________________________
Address __________________________________________________________Phone_______________________
Health Insurance Policy Number ____________________________________________________________________
Athlete�s Doctor�s Name and Phone _________________________________________________________________
Hospital of Choice ______________________________________________________________________________
The following numbers are required so a parent can be reached at all times whenever the athlete is playing hockey:
Mother�s Telephone Number(s)
Home ____________________Work ____________________ Car/Cell ______________ Pager _________________
Father�s Telephone Numbers
Home ____________________Work _____________________ Car/Cell _____________ Pager _________________
If Mother/Father not available, the following will know their whereabouts at all times: (for each, print name & telephone(s), car/cell phone(s), pager(s) numbers.
a)____________________________________________________________________________________________
b) ____________________________________________________________________________________________
c) ____________________________________________________________________________________________