Amateur Sports Team Travel Emergency Consent

Team Name Event/Destination Date(s) of Travel

Athlete Information

Athlete Full Name Date of Birth Address

Parent/Guardian Information

Phone Number Email

Health & Insurance Information

Primary Physician Physician Phone Insurance Provider Policy Number Allergies or Medical Conditions Current Medications

Emergency Contact (Other than Parent/Guardian)

Name Relationship Phone Number

Consent

I, the undersigned parent or legal guardian of the above-named athlete, hereby authorize the coaching staff, team representatives, or chaperones to act in my place in the event of a medical emergency for the duration of the team activity or travel. This authorization includes, but is not limited to, the authority to consent to any necessary medical treatment for my child.