Shermans Dale Girls Softball Association - (Shermans Dale, PA)

2021 Player Medical Information Form

* In case of an emergency, if Parent, Guardian or Family Physician cannot be reached, I hereby authorize my child be treated by Certified Emergency Personnel (i.e. EMT, First Responder, ER Physician).:

Yes

No (Understanding this will prevent my child from participating in any activities held by SDGSA)

* Players First Name:

* Players Last Name:

* Family Physician:

* Phone Number:

* Preferred Hospital:

* In case of an emergency, contact:

* Emergency contact Cell Phone:

In case of an emergency, contact:

Emergency contact Cell Phone:

* Please list any Allergies, Medications or Medical Problems including maintenance Medications (i.e. Diabetic, Asthma, Seizure, ADHD, ADD):

* indicates required fields