Abington Youth Football

Medical Permission Form

In addition to our regular registration form, you are required to fill out and sign this medical permission form.  In the case of an emergency that would require immediate medical attention, your signature on this form would allow the hospital doctor to provide care in the event that you cannot be reached.

Children’s name (s):

___________________________________________________________________________

___________________________________________________________________________

Medical Information:

Insurance Information:______________________________________________________

Policy Number:______________________________________________________________

Local Hospital Preference:____________________________________________________

Family Doctor:__________________________________ Phone:______________________

Please list any allergies and all other pertinent medical information:

       Child                                                            Medical Info.

_________________________    __________________________________________________

_________________________    __________________________________________________

Primary Contact:

Name:_____________________________________________________________________________________

Address:___________________________________________________________________________________

Home #:___________________________________ Cell#:__________________________________________

Relationship:_______________________________________________________________________________

NOTE:  If we are unable to contact  you, please indicate the name, phone,and relationship of that person you would like us to contact in the spaces provided below.

Secondary Contact:

Name:_______________________________________________________________________________________

Address:_____________________________________________________________________________________

Home#:_____________________________________ Cell#:___________________________________________

Relationship:_________________________________________________________________________________

Permission Granted:

____________________________________________________________    _________________________   ______________________

(Signature of Parent or Guardian)                                                          (Print)                                        (Date)