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ROCKY MOUNTAIN NORDIC

Athletic Medical Consent Form

 

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, X-Ray examinations and immunizations for the above named individual.  In the event of serious illness, the need for major surgery, or significant accidental injury, I understand that an attempt will be made by the attending physician to contact me in the most expeditious way possible.  If said physician is not able to communicate with me, the treatment necessary for the best interest of the above named individual may be given.

In the event that a medical emergency arises during a practice session or athletic meet or training camp, an effort will be made to contact the parents or guardians as soon as possible.  Permission is also granted to the coaches to provide the needed emergency treatment to athlete prior to his admission to the medical facility.

Date: March 29, 2020

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Additional Information

Phone Numbers where Parents/Guardian can be reached:


Home: *

Work: *

Cell: *

Home:

Work:

Cell:

Family Physician


Phone: *

After hours telephone #: *
Allergic to any Drugs or Medicines?*

If Yes, what:

Health problems that we should be aware of (Asthma, Diabetes, Etc):

Health Insurance Company


Group Insurance Number: *

Individual Insurance Number: *
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
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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