Parental Consent & Pediatric Athlete Medical Form
Athlete Information
First Name
Last Name
Date of Birth
Gender
Male
Female
Other
Address
City
State
Zip Code
Parent/Guardian Information
Name
Relationship
Phone
Email
Emergency Contact
Name
Relationship
Phone
Medical Information
Allergies
Current Medications
Medical Conditions
Primary Physician
Physician Phone
Insurance Provider
Policy Number
Parental Consent
I, the undersigned, consent to my child’s participation in the designated athletic activities and authorize emergency medical treatment as deemed necessary by medical personnel.
Parent/Guardian Signature
Date