Emergency Contact and Medical Release Form

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Emergency and Medical Information – Step 1 of 2

General Player Information

Player Name

First

Last

Date of Birth

Parent/Guardian Name

First

Last

Parent/Guardian Phone Number

Parent/Guardian Email

Emergency Contact 1 Information

In case of emergency, this person will be contacted.

Emergency Contact Name 1

First

Last

Relationship to Player

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Primary Phone Number

Secondary Phone Number

Emergency Contact 2 Information

In case of emergency, if emergency contact 1 was not responding, this person will be contacted.

Emergency Contact Name 2

First

Last

Relationship to Player

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Primary Phone Number

Secondary Phone Number

Health Insurance

This information is collected in case of emergency.

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Health Insurance Provider

Policy Number

Group Number (If applicable)

Medical Information

Please indicate any medical conditions, allergies, or special needs that the Forge Hockey academy should be aware of.

Does the player have any allergies we should be aware of? Please list if so.

For any allergies listed above, does player have an Epi-pen?

Severity and reactions to allergies listed above

General treatment for allergies listed

Signs of reaction

Medical conditions

Medications currently taking

Previous injuries or surgeries

Any physical limitations or restrictions

Consent for Medical Treatment and Medical Release Form

Player Name

First

Last

Date of Birth

In the event of a medical emergency, all reasonable efforts will be made by Forge Hockey Academy personnel to contact me or my emergency medical contacts. When such contact is unsuccessful, or when delay would endanger the life of my child, Forge Hockey Academy is authorized to administer and/or secure emergency medical treatment for my child, ___________(player name), including hospitalization.

I hereby confirm that the health information provided herein is accurate. I give consent for information relevant to my child’s health and safety to be released on a need-to-know basis. I will notify Forge Hockey Academy in the event of any medical information changes or updates occurring during the time of the program my child is participating in.

I _________(parent/guardian name), grant Forge Hockey Academy all authority and permissions indicated on this form by my selections. I understand that all authority and permission granted herein will be valid and enforceable unless rescinded explicitly in writing by me.

Consent for Medical Treatment and Medical Release

I understand that in the event of a medical emergency, all reasonable efforts will be made by Forge Hockey Academy personnel to contact me or my emergency medical contacts. When such contact is unsuccessful, or when delay would endanger the life of my child, Forge Hockey Academy is authorized to administer and/or secure emergency medical treatment for my child, including hospitalization.

Health Information

I hereby confirm that the health information provided herein is accurate. I give consent for information relevant to my child’s health and safety to be released on a need-to-know basis. I will notify Forge Hockey Academy in the event of any medical information changes or updates occurring during the time of the program my child is participating in.

Permissions

I grant Forge Hockey Academy all authority and permissions indicated on this form by my selections. I understand that all authority and permission granted herein will be valid and enforceable unless rescinded explicitly in writing by me.

Electronic Signature

Clear Signature

Parent/Legal Guardian Name

First

Last

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