2006
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.
Comments (0)
You don't have permission to comment on this page.