To All Parents:

Since the malpractice question has come to the forefront, many hospitals and doctors will not treat a child without parent’s consent (unless a matter of life or death). It is requested that you complete the information below so that if your child requires a visit to the hospital while under the supervision of the school, this will allow the hospital to treat the injury.

Name: __________________ Sport: ________ Sex: M __ F __

Grade: ___Age: ____Date of Birth: _____/_____/_____

Parent’s Name: _____________________________________

Father’s SS#: _____________ Mother’s SS#: ____________

Work Address: ______________________________________

Phone Number: ____________________________

Home Address: _______________________________________

Phone Number: ____________________________

Another Person to Contact: ___________________________

Relationship: ____________ Phone Number: ___________

Insurance Name: ____________________________

Policy and Group Numbers: __________________________

ALLERGIES: _____________________________________________

Consent Statement: Authorizing Treatment

Parent’s Signature: _______________________________