|
ARDYDL Emergency Medical Information |
| This form should be in the possession of the coaching staff at all practices and games. |
| Player's Name: | Date of Last Tetanus Shot: |
| Gender: | |
| Age: | List of Allergies: |
| Date of Birth: | |
| Address: | |
| City: Zip: | |
| Home Phone: | |
| Mobile Phone: | Current Medications: |
| Mother or Guardian: | |
| Mother's Work Phone: | |
| Father or Guardian: | |
| Father's Work Phone: | Additonal Comments: |
| Family Physician: | |
| Physician's Phone: | |
| Insurance Company: | |
| Policy Number: | |
| Whom Else May We Call?: | |
| Phone: |
Parental or Guardian Consent for Coach In the event of an emergency which the coach believes may require medical attention, I/We grant permission to the coach or his/her designee to call for an ambulance and/or to give consent to any medical diagnosis or treatment by a licensed physician. Parent/Guardian Signature: Parent/Guardian Signature: |