Does your child have any dangerous medical conditions that I should know about (such as asthma?)

If so, list them below. Also, please sign to authorize emergency treatment.

1.

Child's Name:

_______________________________________________________________________________

2.	How can you be reached in an emergency?

Tel. No:	_______________________________________________________________________________
Cellular:	_______________________________________________________________________________
Pager:	_______________________________________________________________________________

3.

Dangerous medical conditions (e.g., asthma):

________________________________________________________

	___________________________________________________________________________________________
	___________________________________________________________________________________________

4.

Is there anything a doctor should know (e.g., drug allergies):

____________________________________________

	___________________________________________________________________________________________
	___________________________________________________________________________________________

5.	In a medical emergency, I authorize the coach and related personnel (such as assistants or parents of other team members) to take my child to the closest hospital for treatment.

Sign here: ____________________________________________________________________________________