Blytheville Baseball Softball Boosters

Medical Consent Form

 

NAME OF PLAYER _________________________________ Player’s Age ________________

HOME ADDRESS _________________________ CITY ________________ STATE___________

FAMILY PHYSICIAN_____________________________________ PHONE _________________

LIST OF ANY ALLERGIES _________________________________________________________

____________________________________________________________________________

REQUIRED MEDICATIONS _______________________________________________________

____________________________________________________________________________

In case of an accident or illness, I hereby authorize a representative of Blytheville Baseball Softball Boosters to use his/her judgment in obtaining immediate Medical Care.

DATE ______________     SIGNED ___________________________________

                                                                                (PARENT OR GUARDIAN)

 

DAYTIME PHONE ___________________ HOME PHONE __________________

 

CELL PHONE ______________  PARENT’S HEALTH INS. CO. ________________

                                                                        POLICY # _______________________________

 

(Parents will be notified in case of serious illness or injury as quickly as they can be reached, but this will make immediate treatment possible.