Medical Form
_
This must be completed- legibly- and signed in all areas by both the athlete and his/her parent or guardian. By signing this form the participant affirms having read it.
Name ___________________________________________________________________________________________
Last First Birth Date Age Gender
Primary Contact: Parent or Guardian
Name ________________________________________ Address _________________________________________Zip__________
Phone _____________________________________________ Alternate Phone ___________________________________________
Secondary Contact: ____Parent/Guardian ____Other
Name ________________________________________ Address _________________________________________Zip__________
Phone ___________________________________ Alternate Phone ____________________________________________________
Primary Insurance Co. ___________________________ Primary Group/Policy # __________________________________________
Family Physician Name __________________________ Physician Phone ________________________________________________
Please elaborate on any medical conditions of which we should be aware:
Any medications currently being taken:
Any allergies:
If none, please write None.
Signed ________________________________________ Date: _________________________
Participant
Participant, ____________________________ has my permission to participate in training, competition, events, activities and travel sponsored by the
Gold Rush Athletic Club or any AAU/USATF meet. I approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed above. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above.
Signed ___________________________ Relationship: _____________________ Date: ________________
If, during the course of my daughter’s/son’s activities in the program, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for bills incurred through my insurance company.
Signed ____________________________ Date: __________________________________________________
Parent or Guardian
Or
I do not authorize emergency medical/dental care for my daughter/son.
Signed: __________________________________________________ Date: _____________________________________________
Parent or Guardian
STATE OF ___________________________________ COUNTY OF __________________________________________________
SWORN TO BEFORE ME, a Notary Public, by said ____________________________________ personally know to me this __________________ day of ______________________, ,20 ______.
____________________________________________ My Commission Expires _______________________________
Notary Public
This must be completed- legibly- and signed in all areas by both the athlete and his/her parent or guardian. By signing this form the participant affirms having read it.
Name ___________________________________________________________________________________________
Last First Birth Date Age Gender
Primary Contact: Parent or Guardian
Name ________________________________________ Address _________________________________________Zip__________
Phone _____________________________________________ Alternate Phone ___________________________________________
Secondary Contact: ____Parent/Guardian ____Other
Name ________________________________________ Address _________________________________________Zip__________
Phone ___________________________________ Alternate Phone ____________________________________________________
Primary Insurance Co. ___________________________ Primary Group/Policy # __________________________________________
Family Physician Name __________________________ Physician Phone ________________________________________________
Please elaborate on any medical conditions of which we should be aware:
Any medications currently being taken:
Any allergies:
If none, please write None.
Signed ________________________________________ Date: _________________________
Participant
Participant, ____________________________ has my permission to participate in training, competition, events, activities and travel sponsored by the
Gold Rush Athletic Club or any AAU/USATF meet. I approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed above. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above.
Signed ___________________________ Relationship: _____________________ Date: ________________
If, during the course of my daughter’s/son’s activities in the program, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for bills incurred through my insurance company.
Signed ____________________________ Date: __________________________________________________
Parent or Guardian
Or
I do not authorize emergency medical/dental care for my daughter/son.
Signed: __________________________________________________ Date: _____________________________________________
Parent or Guardian
STATE OF ___________________________________ COUNTY OF __________________________________________________
SWORN TO BEFORE ME, a Notary Public, by said ____________________________________ personally know to me this __________________ day of ______________________, ,20 ______.
____________________________________________ My Commission Expires _______________________________
Notary Public