MEDICAL CARE CONSENT
All players and parents are required to review and sign the Midstates Medical Care Consent Form. Please download a copy at the link to the right. The signed document must be submitted before a player is considered fully registered.
MIDSTATES CLUB HOCKEY ASSOCIATION
www.midstateshockey.us @midstateshockey
Definitive Emergency Medical Care Consent
I, the undersigned parent of ___________________________________________, do hereby consent to have prompt definitive emergency medical care administered to the aforementioned member of my family in my absence, in so doing; I release the administering facility and/or individuals from responsibility for medical service performed. The Midstates Club Hockey Association and/or its Club hockey members and representatives are hereby absolved from responsibility for subsequent consequences occurring there from. If necessary contact our child’s doctor.
Physician: _________________________________________________________
Office Phone: ____________________________________________________________
Exchange: _________________________________________________________
Home Phone: ____________________________________________________________
Signature of Parent or Legal Guardian: ____________________________ Date: ___________
Signature of Parent or Legal Guardian: ____________________________ Date: ___________
If the above parent or legal guardian cannot be reached, in case of emergency contact:
Name: _______________________________ Phone Number: _________________
Please note if child has an allergy or is allergic to any medication.
NOTE: This form is to be kept by the Club and taken to all practices/games, so that it is available if necessary.
For Mid-States Hockey information contact Barb Collumbien at 314-575-7069. 8/25/2018