3Ca Rev 2/16
EMERGENCY CONTACT
Name: _________________________________________________ Phone: (_______)______________
Address: ______________________________________________________________________________
City: ______________________________________ State: _______ Zip Code: ________________
Physician’s Name: ______________________________________ Phone: (_______)______________
Hospital of Choice: _____________________________________________________________________
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.
q
Head Injury
(concussion, skull fracture)
q
Fainting spells
q
Convulsions/epilepsy
q
Neck or back injury
q
Asthma
q
High blood pressure
q
Kidney problems
q
Hernia
q
Heart murmur
q
Allergies ______________
q
Diabetes
q
Other _________________
______________________
______________________
Have you had (or do you currently have) any of the following?
Have you had a recent tetanus booster?
q
Yes
q
No If yes, when? __________________
Are you currently taking any medications?
q
Yes
q
No If yes, please list all medications on back.
Has a doctor placed any restrictions on your activity?
q
Yes
q
No If yes, please explain on back.
USA Hockey National Championships
Consent To Treat/Medical History Form
This is to certify that on this date, I __________________________________________, as parent or
guardian of __________________________________________, (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: _______________________________________________________________
Parent/Guardian/Adult Participant Signature: _____________________________ 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.
click to sign
signature
click to edit
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