Palmyra Girls Softball

Emergency Medical Authorization

Palmyra Girls Softball
Emergency Medical Authorization

* Player's First Name:

* Player's Last Name:

* Address:

* City:

* State:

Purpose: To enable parents/guardians to authorize the provision of emergency medical treatment for their minor child who become ill or injured when parents/guardians cannot be reached.

* Parent/Guardian Name:

* Cell Phone:

Work Phone:

* Email Address:

Additional Contact Name:

Cell Phone:

I hereby give consent for the following medical care providers and/or local hospitals to be called in case of emergency.

I/we agree with the above *

* Physician:

* Physician's Phone:

* Dentist:

* Dentist's Phone:

* Hospital:

* Hospital's Phone:

Medical Specialist:

Medical Specialist's Phone:

In the event reasonable attempts to contact me/us have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by the above-named doctors, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible.

This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists concur that such surgery is necessary and are obtained prior to the performance of surgery.

Facts concerning the player?s medical history, including allergies, medications currently being taken and any physical impairments to which a physician should be alerts are as listed:

Allergies:

Current Medications:

Physical Impairments:

Additional Medical History:

* indicates required fields

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Emergency Medical Authorization