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Our Lady of Lourdes - EMERGENCY MEDICAL TREATMENT AUTHORIZATION

PLEASE READ THIS WHOLE FORM BEFORE YOU FILL IN FIELDS. USE YOUR CHILD'S FULL LEGAL NAME - NO NICKNAMES!

Player	Last Name	First Name	M.I.
Address	Street / Apartment #	City	State	Zip Code
Date of Birth			Current Age
School		Current Grade
Parish
Parent 1	Last Name	First Name
Parent 1's Phone	Home	Cell	Work
Parent 2	Last Name	First Name
Parent's 2 Phone	Home	Cell	Work
Family Physician		Physician's Phone
Do You Have Medical Insurance?
Insurance Company Name			Policy #
***NOTICE TO ALL PARENTS - Prior to participation in any physical activity, player should see their family physician. We need your permission to treat your child in case of an emergency at practice sessions or during any athletic event.
You have my permission to have my child listed above treated in case of an emergency. I prefer that my child be treated for injuries by:
Hospital
Is your child pre-registered at this hospital?
By selecting the option below marked YES, you are acknowledging that your child is a student at Our Lady of Lourdes Catholic Grade School or actively participates in ERE classes in accordance with the CSAA Regulations. Parent /Guardian acknowledges too that they are familiar with all guidlines, codes of behavior and expectations for student athletes contained in the Athletic Handbook I agree
Your Name: Email:
For questions or problem with this for email webdesign@ourlourdes.org for reporting issues/problems.