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Medical Information & Waiver Forms

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Medical Information & Waiver Forms Page 2
Medical Information & Waiver Forms
USA WRESTLING
PARENT'S INSTRUCTIONS ON MEDICAL TREATMENT
PLEASE PRINT IN CAPITAL LETTERS
Wrestler's Name Date of Birth
Parent/Guardian Name
Relationship
Address
Home Phone
Work Phone
Please indicate another person to call it an accident occurs and we are unable to reach you:
Name
Phone No.
Insurance Company
Policy No.
Family Doctor
Phone No.
Is your child presently on medication
If yes, please list medication (s):
Drug Sensitivities
Other Allergies
Date of your child's last complete physical examination by a medical doctor
If this is more than one year ago, please complete the accompanying medical history questionnaire.
Please read the alternative statements below and sign under the one that you choose. Sign only one!
1. If my child needs medical attention, it is my wish that I am contracted before any medical procedures are
taken on my child, unless immediate treatment is necessary to save my child's life or to prevent permanent
injury.
Parent/Guardian Signature
Date Signed
2. If my child needs medical treatment while participating, it is my wish that the treatment is started while
efforts are being made to contact me. So that treatment is not delayed, I consent to any medical
procedures that the physician believes are needed, on the understanding that efforts to contact me will
continue to be made. I accept responsibility for all costs related to such treatment.
Parent/Guardian Signature
Date Signed
Wrestler's USA Wrestling Card No.
Name of Club
Coach's Name
Phone Number
Medical Information & Waiver Forms