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Consent to Treat Form 2006

Page history last edited by PBworks 15 years, 4 months ago


MALA – Consent to Treat Form



This is to certify that I,____________________________, as parent or guardian of _________________________________, give my consent to Madison Area Lacrosse Association, our team’s coaches and representatives to obtain medical care from any licensed physician, medical care provider, hospital, or clinic for the above mentioned athlete, for any injury that could arise from participation in the game of lacrosse.


Name of Insurance Company___________________________________________________________

Address ________________________________________ Phone _____________________ Policy Number ________________________________ Insured # ______________________


In case of Emergency, please notify:


Player’s Name __________________________________________________________________

Parent/Guardian #1 ______________________________________________________________

Address _______________________________________________________________________

Home Phone #_________________Work # _______________Cell Phone # _________________

Parent/Guardian #2 ______________________________________________________________

Address _______________________________________________________________________

Home Phone #_________________Work # _______________Cell Phone # _________________

Emergency contact (if parents/guardian unavailable) ________________________________________ _______________________________________________________________________________


Doctor’s Name_________________________________ Phone____________________________

Clinic Address_______________________________________________

Hospital Preference___________________________________________


If emergency treatment is required and the parent/guardian cannot be reached immediately, may team coaches and representatives use their own judgement in calling the physician indicated on the Medical History Form or if not available, an alternate physician or medical provider? YES NO

(if no, please indicate alternate plan to follow) __________________________________________________________________________________________________________________________________________________________________


Parent/Guardian Signature ____________________________________Date________________


Team Reps: Please give original Consent Form to the coach and keep a copy for your records.

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