Printable Form  MEDICAL HISTORY RECORD/PERMISSION TO PARTICIPATE

 

BHBL Function: __________________ (ex: summer camp, Fall Ball, Tournament, Playday)

 

 

Player’s Name: _____________________________ Date of birth: _______________

 

Parents’ or legal guardians’ name: ________________________________________

 

Home phone: ______________________ Cell phone: ________________________

 

Emergency contact: _______________________ Phone: _______________________

 

Emergency contact relationship: __________________________________________

 

Hospital of choice in emergency: __________________________________________

 

Date of child’s last Tetanus immunization: __________________________________

 

List any daily-prescribed medication: ______________________________________

 

Known allergies: ________________________________________________________

 

Recent injuries, illnesses, and/or physical restrictions: ________________________

 

_______________________________________________________________________

 

I hereby give my permission for my child to participate in all activities at the BHBL field hockey above event. I verify that she/he is physically able to participate in all activities. If necessary, I allow my child to be treated by a physician or athletic trainer while attending the event. Furthermore, I authorize my child to be transported to a local hospital should she require emergency treatment.

I am fully aware that the event does not provide primary Medical insurance for its participants. I am prepared to accept responsibility for injuries or medical complications that may result from participation in the tournament.

 

 

________________________________________________________________________

Signature of Parent or Guardian Date

 

***Please sign and return to your coach. This must be done before participation in

the BHBL field hockey event can take place. No exceptions will be made.