Rockland Youth Football and Cheerleading

MEDICAL PERMISSION FORM

In addition to our regular registration form, you are required to fill out and sign this medical permission form.  In the case of emergency that would require immediate medical attention, your signature on this form would allow the hospital doctor to provide care in the event that you cannot be reached.

Child’s Name & Address:___________________________________________________

________________________________________________________________________

Medical Information:

Insurance Information: _____________________________________________________

Policy Number: ___________________________________________________________

Local Hospital Preference: ________________________  DOB: ____________________

Family Doctor: __________________________________ Phone: ___________________

Any allergies to foods, drugs, insects, etc?

________________________________________________________________________

Any history of breathing problems or asthma? Do you need an inhaler? __________

Any medical condition or previous injury that may prohibit you from full participation?

________________________________________________________________________

Contact Numbers:

Primary Contact:

Name: __________________________________________________________________

Address: ________________________________________________________________

Home (phone): ________________________ Work (phone): ______________________

Cell: ________________________________  Relationship: _______________________

NOTE:  If we are unable to contact you, please indicate the name, telephone number, and relationship of the person that you would like us to contact in the spaces provided below:

Secondary Contact:

Name: __________________________________________________________________

Address: ________________________________________________________________

Home (phone): ________________________ Work (phone): ______________________

Cell: ________________________________  Relationship: _______________________

Permission Granted:

_______________________________  _________________________  Date: _________

          (Signature of Parent or Guardian)                              (Print)