LANCER RUGBY CLUB
MEDICAL EMERGENCY FORM
MEDICAL EMERGENCY FORM
Name_______________________________
Parent/ Legal Guardian_____________________________
Home Phone_________________ Business Phone_________________
Your child must be covered by a health insurance plan. Rugby is a contact sport and injuries can happen and risks of serious injury do exist including permanent disability and death which may result from your own actions, inactions of others, the rules of play, or the conditions of the premises or of any equipment used. Further there may be other risks not known to us or not reasonably foreseen at this time. Your signature indicates that you are aware of the potential injury risks that could occur during a properly supervised practice or game and that you have given permission for your son/ daughter to participate and that you have fulfilled its medical insurance coverage requirement in Section 8 of the Waiver of Liability and Eligibility form.
Parent/ Legal Guardian Signature ________________________________
Parent/ Legal Guardian Signature ________________________________
Date________________
Athlete Signature ____________________________
Date________________
MEDICAL EMERGENCY AND INSURANCE INFORMATION
(Please include a copy of your insurance card)
(Please include a copy of your insurance card)
Emergency Contact__________________________
Relationship ___________________
Emergency Contact Phone_____________________
Medical Insurance Company_________________________
Policy#_____________________
I, the natural parent/ legal guardian, authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child’s health and I cannot be contacted. I waive my right of informed consent to such treatment.
Parent/ Legal Guardian Signature____________________________
Date_________________
Policy#_____________________
I, the natural parent/ legal guardian, authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed for my child by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard my child’s health and I cannot be contacted. I waive my right of informed consent to such treatment.
Parent/ Legal Guardian Signature____________________________
Date_________________