Fremd HS Girls Feeder Basketball - (Palatine, IL)

Emergency Medical Release Form

Player Name:

Note: For all players who make a team, this form will need to be printed out and signed before practices begin.

Fremd Girls Feeder Emergency Medical Release 2021-2022 Season

Participant's name_____________________________________ Birth date: _____________________

Father's Name ___________________________________________ Cell Phone _____________________

Mother's Name ___________________________________________ Cell Phone ____________________

In an emergency when parent/guardian cannot be reached, please contact the following:

Name ______________________________________ Cell Phone ___________________ Cell Phone ________________
OR
Name ______________________________________ Cell Phone ___________________ Cell Phone ________________

Participant Allergies: _____________________________________________________________________________

Other medical conditions: _________________________________________________________________________

Physician Name: __________________________________________________ Phone ________________________

Insurance Provider: _____________ ___________________________________ Phone _________________________

THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT WILL BE USED FOR TREATMENT FOR INJURY BASED ON THE INFORMATION PROVIDED.

Parent/Guardian Signature _____________________________________________________ Date _______________

Parent/Guardian Comments (if desired) _______________________________________________________________

_____________________________________________________________________________________________
NOTE: PLEASE ATTACH COPY OF YOUR INSURANCE CARD BOTH FRONT AND BACK.

* indicates required fields