Players Name__________________________

Players date of Birth _____________________

As the parent of legal guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.

Signature of Parent / Guardian ________________________________

Date______________________________

Allergies to Medicine_______________________________________________________________

Doctor__________________________________________________________________________

Insurance Company________________________________________________________________