Fall Registration 2020-21 (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*

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 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

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...

Fall Registration 2020-21 (Consent to Treat)

CHICAGO MISSION FALL REGISTRATION
2020 - 2021

CONSENT TO TREAT

EMERGENCY CONTACT

COMPLETION OF MEDICAL HISTORY INFORMATION BELOW IS OPTIONAL

Medical History

Fall Registration 2020-21 (Consent to Treat)

CHICAGO MISSION FALL REGISTRATION 2020 - 2021

CONSENT TO TREAT

EMERGENCY CONTACT

COMPLETION OF MEDICAL HISTORY INFORMATION BELOW IS OPTIONAL

Medical History

CHICAGO MISSION FALL REGISTRATION
2020 - 2021