St. Paul FSC Emergency Medical Reference Form 2020-2021

Skater Information

Skaters First Name *

Skaters Last Name *

Street Address *

City/State/Zip *

Primary Phone Number *

Parent/Guardian Information

Complete if your skater is a minor.

1st Parent/Guardian Name

1st Parent Address (If different from above)

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Email Address

2nd Parent/Guardian Name

2nd Parent Address (If different from above)

City

State

Zip Code

Primary Phone Number

Secondary Phone Number

Email Address

Emergency Contact

Name *

Phone *

Primary Doctor

Phone

Dentist

Phone

Orthodontist

Phone

Hospital Preference

Medical Insurance Provider

Policy Number

Pre-existing Conditions

Check where applicable:

Glasses/Contacts

Asthma

Diabetes

Does skater have any allergies? *

Yes

If yes, please list:

Please provide any additional medical conditions/allergies or information that you feel would be pertinent for a rescue team to know:

Authorization

In the event of a serious injury or illness, if an emergency contact/parent/guardian cannot be reached, I hereby authorize the doctor or treatment center listed above to treat myself, or my child. If necessary, an ambulance may be called. Cost of the ambulance is my responsibility. Please sign below: * 🛈

clear

Date Signed: *

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