- I, the undersigned parent of
______________________________________________,
- do hereby consent to have prompt definitive emergency medical care
administered to the aforementioned member of my family in my
absence, in so doing, I release the administering facility and/or
individuals from responsibility for medical service performed.
The Mid-States Club Hockey Association and/or its club hockey
members and representatives are hereby absolved from responsibility
for subsequent consequences occurring there from. If necessary
contact our child's doctor.
His name is
___________________________________________________________
and his phone is Office _____________________________
Exchange _______________________________________
Home _________________________________________
- ____________________________________________
______________
- Signature of
Coach/Witness
Date
- ____________________________________________
______________
- Signature of Parent or Legal
Guardian
Date
-
If the above cannot be reached, in case of emergency call:
- _____________________________________________
_______________
- Name
Phone Number
Please note if child has an allergy or is allergic to any medication!
Note: This form is to be kept by club and taken to all
practices and games, so that it is available if necessary. |