MID-SOUTH POP WARNER EMERGENCY MEDICAL AUTHORIZATION

Participant's Name: ___________________________________________________Age:_________________________
Date of Birth: ___________________________________ Social Security Number: _____________________________
Parents/Guardian Name: ____________________________________________________________________________
Home Phone: ___________________ Work Phone: _____________________ Cell Phone:_______________________
Address: _________________________________________________________________________________________
Email Address: ____________________________________________________________________________________
Family Doctor: ___________________________________________ Phone Number(if known)______________________________
Preferred Hospital for Treatment: _____________________________________________________________________

PROVIDE EMERGENCY CONTACT INFORMATION IN THE EVENT WE CANNOT CONTACT YOU:
Name: ___________________________________________________________________________________________
Relationship to Child: ____________________________________ Phone: ___________________________________
Name: ___________________________________________________________________________________________
Relationship to Child: ____________________________________ Phone: ___________________________________

LIST ANY ALLERGIES (Bee Stings. medicine, etc) OR CONDITIONS (asthma, seizures, diabetes, etc.) WHICH THE ORGANIZATION SHOULD BE AWARE OF:
____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________
List any prescribed medication that your child is currently taking:
____________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Additional medical information that may be helpful:
_________________________________________________________________________________
________________________________________________________________________________
Participant's Health Insurance Company: ________________________________Policy Holder____________________ Policy Number ___________________________________ Group Number___________________________________

I hereby give my consent for medical treatment deemed necessary by physicians designated by the organization and/or for transportation to a hospital emergency room for the treatment of any illness or injury resulting from his/her athletic participation. I understand this authorization will only be enforced when I cannot personally be contacted and provide for immediate treatment.

Signature of parent/guardian__________________________________________________________
Date_______________________________________