2017 thunder fastpitch emergency medical form


2017 thunder fastpitch emergency medical form...

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2017 THUNDER FASTPITCH EMERGENCY MEDICAL FORM & CONSENT TO TREAT Athlete’s Name: ___________________________ Parents’ Name: ___________________________ Notify in Case of Emergency: ____________________ ● Relation to Athlete: _____________ ● Home Phone: _____________ ● Cell Phone: _____________ Alternate Emergency Contact: ____________________ ● Relation to Athlete: _____________ ● Home Phone: _____________ ● Cell Phone: _____________ Physician/Clinic:________________________________________ Insurance Company: _______________ Policy/Grp #: _______ Please list any allergies, health problems, or medications required. If none, please indicate by initialing here: _________

CERTIFICATION OF PHYSICAL CONDITION AND MEDICAL CONSENT​: I certify to the best of my knowledge, my daughter has no physical or mental conditions which prohibit her from participating in Thunder Fastpitch activities. By signing below, I hereby consent to any emergency medical treatment as approved by her manager or other persons associated with Thunder Fastpitch in case of illness or injury while participating in all levels of play, practice, travel or any other Thunder Fastpitch activities. I fully release Thunder Fastpitch, its board members, and persons associated with Thunder Fastpitch from and against any claim, demand or liability.

Parent or Guardian Signature: ____________________________________________ Date: __________________________