Murrieta Mavericks Cheerleading

Emergency Medical Treatment, Consent and Information
The following information will be used in the event that a parent / legal guardian is not available. The purpose of this
information is to provide a quick reference for medical personnel should the need arise. Please fill out this form completely.
If a particular question is not applicable write "none", n/a, or other appropriate comment otherwise none will be assumed.be assumed. If additional space is needed, please use the back of this form or attach additional pages as needed.
All information disclosed here will be treated as confidential. It will be the responsibility of the parent/legal guardian to notify the participant's coach and league/event officials if any information needs to be added, deleted, changed, or updated in any way.
Athlete's Name:
Address:
ATHLETE INFORMATION
Nick Name:
City:
Phone:
State: Zip:
PARENT OR GUARDIAN INFORMATION
Father's Name:
Address:
Hm Phone:
Employer:
City:
Daytime Phone:
State: Zip:
Email:
Mother's Name:
Address:
Hm Phone:
Employer:
Guardian's Name:
Address:
Hm Phone:
Employer:
C i t y :
Daytime Phone:
S t a t e : Z i p :
Email:
City:
Daytime Phone:
State: Zip:
Email:
Carrier:
Policy #:
Policy Holder Name:
Family Physician's Name:
Dr's Address:
Phone:
FAMILY MEDICAL INSURANCE
Group:
Group #:
City: Fax: Email:
EMERGENCY MEDICAL INFORMATION
State: Z i p :
Preferred Hospital(s):
EMERGENCY CONTACT: Phone: Relationship:
Please list any medical conditions (allergies, asthma, etc.) And medications being taken by the participant named above. Please list any other information you may
above. Please list any other information you may deemed relevant, and helpful to emergency medical personnel:

Please note if no information is given and the words "none" or "n/a" is not filled in then, "none" will be assumed.
Allergies:
Medical Conditions:
Other:
*| as evidenced below hereby grant permission for my child/ward to participate in any and all, Murrieta Mavericks Events & programs events),
including but not limited to, athletic, social and/or fundraising activities. I further consent to the administration of any and all medical treatment necessary to stabilize and or treat any medical or medical emergency to which my child/ward is afflicted. I understand that this authorization is given prior to the need for medical care, but given in
advance to avoid any unnecessary delay in emergency treatment which the attendant and/or medical professional may deem advisable in the exercise of their best judgment.

*Print Parent/Legal Guardian Name
*Signature Parent/Legal Guardian *Date

The original Emergency Medical Treatment, Consent and Information form should travel with the coach and a copy should be kept at the
administrative office of the sports organization. Due to privacy concerns, completed forms should be stored

Murrieta Mavericks Cheer 26-27 Season 17 Registration Inquiry