Authorization For Emergency Care

Players Name:			Date of Birth:
Players Age:
Fathers/Guardian Name:			Business #:
Cell #:			Pager #:
Mothers/Guardian Name:			Business #:
Cell #:			Pager #:
Physician's Name:			Phone:
Insurance Co.:			Policy #:
Person(s) to contact for my child in case of emergency or major illness if i cannot be reached.
Name:			Address:
Relation:			Home Phone:
Cell Phone:			Pager:
Name:			Address:
Relation:			Home Phone:
Cell Phone:			Pager:
Record of any operation, injury, or major illness this participant has had in the past 12 months, and give approximate dates:
Allergies: