ESDAA Tournament Medical Form

Student: _____________________________ Age: _________ DOB: ____________

Parent/Guardian: _______________________________________________

Address: _______________________________________________

Home Phone: ________________________ Work Phone:

Emergency Contact: ___________ Phone: ___________

Describe any physical/medical issues: (ie.: seizures, diabetes, etc.)

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Date of last tetanus shot: ___________________________

List any allergies to food or medication:
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List any medication to be given. Include the drug, dosage and reason for medication. (Also, please fill out the attached medication permission form(s).)
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Private Physicians' Name: ____________________ Phone: ________________

Medical Insurance Co: ________________________

Medical / Medicaid Insurance Policy Number: ________________________

Medical Insurance Policy Holder: ________________________

I,___________________________, hereby give permission for my child to receive medical treatment at any time due to an emergency while present at the ___________________________(school name), in ________________________ (city/state) on _____________ (date).

I accept all responsibility for medical, hospitalization, and liability that may arise from this tournament. I understand that any charges incurred for such treatment are responsibility and agree to pay for any such charges not covered by my insurance.

Parent/Guardians' Signature: ____________________________________ Date:

Revised 3l'30/04