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2017 HEAVENLY TRACK CLUB MEDICAL TREATMENT PERMISSION FORM

In the event of an emergency occurs while my child is on an Heavenly Track Club sponsored practice, track meet and/ or trip, I grant permission to the team to take whatever action necessary, including notifying me (parent/ guardian) immediately. In the event that I cannot be reached, I hereby authorize the coach, administrator, or any board member to give consent for my child, to receive medical treatment.

ATHLETE INFORMATION

* First Name:

Middle Name:

* Last Name:

Birthdate:

Gender:

* Parent/Guardian Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

Cell Phone:

Business Phone:

EMail:

MEDICAL/EMERGENCY CONTACT INFORMATION

Person to be notified other than a parent or authorization for consent to medical treatment.

Emergency Contact:

Relationship to Athlete:

Home Phone:

Work Phone:

Cell Phone:

What procedures should be followed?:

Insurance Carrier:

Policy #:

MEDICAL INFORMATION

* Do you have any medical problems that running track could aggravate?:

Yes

No

If Yes, explain:

Click all that apply

* Heart condition or diseases:

Yes

No

* Diabetes:

Yes

No

* Convulsions disorder:

Yes

No

* Asthma:

Yes

No

* Allergic to medication:

Yes

No

* Allergic to insect stings:

Yes

No

List Allergies:

List any medication (s) currently receiving:

* Date of last Tetanus shot:

* Date of last Physical Exam:

Additional medical information that may be helpful:

I/we agree with the above *

Signature:

Date:

Signature:

Date:

* indicates required fields

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