Main Page
Mission Teams
BOYS TEAMS
Boys 10U (11’s)
Boys 11U (10’s)
Boys 12U (09’s)
Boys 13U (08’s)
Boys 14U (06’s)
Boys 15’s (05’s)
Boys 16U
Boys 18U
GIRLS TEAMS
Girls 12U
Girls 14U
Girls 16U
Girls 19U
Contacts
Information
About
Home Rinks
Tryouts
Spring Program 2021
Fall Tryouts – Coming Soon
Apparel
Hats
Fundraiser CHICAGO Hats
Mission Hats
Transport to Canada Consent
News
Alumni
Boys
Girls
National Champions
Drafted to Juniors
Fall Registration 2020-21 (Consent to Treat)
CHICAGO MISSION
FALL REGISTRATION
2020 - 2021
.
CONSENT TO TREAT
Mission Team
Player
*
First
Last
This is to certify that on this date, I
Parent or Guardian
*
as parent or guardian of.
Full Player Name
*
, (athlete participant), or for myself as an adult participant, give my consent to USA Hockey and its medical representative to obtain medical care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury that could arise from participation in USA Hockey sanctioned events.
If said participant is covered by any insurance company, please complete the following:
Insurance Company:
*
Policy Number:
*
Signature (Parent/Guardian)
*
Date
*
Date Format: MM slash DD slash YYYY
Excess accident insurance up to $50,000, subject to deductibles, exclusions and certain limitations, is provided to all USA Hockey registered team participants. For further details visit usahockey.com or contact USA Hockey at (719) 576-USAH
EMERGENCY CONTACT
Emergency Name
*
Phone
*
Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physician’s Name
*
Physician’s Phone
*
Hospital of Choice
*
Name, Any, Closest, etc...
COMPLETION OF MEDICAL HISTORY INFORMATION BELOW IS OPTIONAL
Medical History
If the answer to any of the following questions is yes, please describe the problem and its implications for proper first aid treatment on the back of this form.
Med History
Head Injury
Fainting spells
Convulsions/Epilepsy
Neck or back injury
Asthma
Med History 2
High blood pressure
Kidney problems
Hernia
Heart murmur
Diabetes
Allergies
Alergies
List Allergies
Other
Other
List Other
List Other
List Other
Have you had (or do you currently have) any of the following?
.
Have you had a recent tetanus booster?
*
Yes
No
If Yes, When?
*
.
Are you currently taking any medications?
*
Yes
No
If yes, please list all medications
*
.
Has a doctor placed any restrictions on your activity?
*
Yes
No
If yes, please explain
*
.
Additional Medical Descriptions
Email
*
Confirmation of form will be emailed...
.