Youth Wrestling Meet Emergency Medical Consent
Participant Information
Wrestler's Name
Date of Birth
Age
Parent/Guardian Name
Address
Phone Number
Alternate Phone
Emergency Contacts
Contact Name
Relationship
Phone
Contact Name
Relationship
Phone
Medical Information
Allergies
Current Medications
Medical Conditions
Primary Physician Name
Physician Phone
Medical Insurance Company
Policy Number
Group Number
Consent and Authorization
I, the parent or legal guardian of the above-named participant, hereby authorize the diagnosis and treatment of my child by qualified and licensed medical personnel in the event of a medical emergency, as deemed necessary by such personnel.
Parent/Guardian Signature
Date