Auburn Elite Track Club - (AUBURN, WA) - powered by LeagueLineup.com

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Medical Emergency Form

ATHLETE INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

Cell Phone:

Home Phone:

* Birthdate:

PARENT/GUARDIAN #1

* Name:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Name:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

* Relationship to Athlete:

* Insurance Carrier:

* Policy #:

I, the parent/guardian named above, hereby authorize the Auburn Elite Track Club coaches and staff to seek immediate medical treatment for my child listed above, if a medical emergency arises while on the way to, returning from or during any practice or meet in which the team participates. I also authorize the attending physician to perform any emergency treatment necessary, after consultation with a coach, if I cannot be reached.

By checking this box and providing my electronic signature below, is valid and legal authorization for the Auburn Elite Track Club to seek the appropriate medical treatment for the athlete. *

* Parent/Guardian Electronic Signature:

* indicates required fields