Emergency Permission Form

Student's Name

First Name

Last Name

Age

Please list any health problems that might be significant to a physician evaluating your child in case of an emergency:

List any medications your child is allergic to:

Is an inhaler or Epi-Pen prescribed?

List the emergency medication:

List any other medication your child is presently taking:

Does your child wear contact lenses?

Date of last tetanus shot:

YYYY

In the event I cannot be reached in an emergency, I hereby give permission to the coaches and staff of Improve Your Game LLC to authorize any and all medical care advised by any licensed surgeon, physician, or other medical personal if it is deemed to be in the best interest of my child. I do hereby indemnify and hold harmless the physician, hospital, and other persons who act in reliance upon this authorization.

I agree

Insurance Company:

Policy number:

Subscriber's name:

Emergency Phone numbers (please list three):

I certify all the above information is correct and agree to update information if an of the information changes.

I agree

Parent/Guardian Name

First Name

Last Name

Date

YYYY

Or download the paper copy.