St. Paul FSC Emergency Medical Reference Form 2020-2021

Skater Information

Parent/Guardian Information

Complete if your skater is a minor.

Emergency Contact

Pre-existing Conditions

Check where applicable:
Does skater have any allergies? *


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: * 🛈