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Authorization of Consent for Treatment of Minor:

( I ) (We) the undersigned parent (s) of a minor, do hereby authorize the designated chaperone listed below, for the undersigned to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of, any physician and surgeon licensed under the provision of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of our aforesaid agent (s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his best judgement may deem advisable.

This authorization shall remain effective until February 2, 2025, unless sooner revoked in writing delivered to said agent (s).

Parental Authorization/Consent Form

The Chaperone has my authorization and permission to provide the following first aide and/or treatment to my child:

A. Tylenol or Motrin, for example, for headache, fever. Over the counter medication for allergies or colds. Bactine, antiseptic sprays, antibiotic ointments, caladryl, for example, for skin inflammations, abrasions, cuts/scrapes, and insect bites. Benadryl, for example, allergic reactions. Mosquito repellent spray or lotions.

B. Render first aide for the treatment of minor wounds, scrapes and bumps.

C. My child has the following medication, prescribed by my child’s physician on him/her: (we are assuming they will be responsible for taking their own medication, unless otherwise stated in writing by you, the parents)

Authorization

The chaperone has my authorization and permission to administer the above over the counter medications as they evaluate is necessary for administering first aide to my child, and any prescribed medication listed above. This authorization shall remain effective from:

Today's Date: May 18, 2025





Please select "Minor(s)" and then the number of Minors to be chaperoned.
Minor(s)
1 Minor2 Minors3 Minors4 Minors5 MinorsMore Minors6 Minors7 Minors8 Minors9 Minors10 Minors
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First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address
Email*
Confirm Email*
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Insurance
Insurance Carrier*
Insurance Policy Number*
Chaperone's Information

Chaperones must keep a signed and completed form either physically or digitally in their possession throughout the tournament. 

Chaperone's First Name *
Chaperone's Last Name *
Chaperone's Email *
Chaperone's Phone *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
Family Doctor
Phone

My child has the following medication and/or supplament: Name of Medication/Supplament

All Allergies (including medications, food allergies, and season allergies)

Describe the reaction and what protocol is to be followed if they come in contact with an allergen?
Does your insurance require a call before admitting to a hospital for emergency purposes?*
No
Yes
If yes, please provide the area Code and phone #
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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