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USA Hockey Consent to Treat/Medical History Avon Canton Farmington Youth Hockey Association
This is to certify as parent or guardian of the below specified athlete participant or for myself as an adult participant, give consent to USA Hockey, Avon Canton, Farmington Youth Hockey Association and its medical representative to obtain medical care form any licensed physician, hospital, or clinic for the below mentioned participant for any injury that could arise from participation in USA Hockey sanctioned events. Excess accident insurance of up to $25,000, subject to deductibles, exclusions, and certain limitations, is provided to all USA Hockey registered team participants. For further details visit usahockey.com or contact USA Hockey at 719-576-USAH. This completed form will be sent to Avon Canton Farmington Youth Hockey Association registrar. If you have any problems with completing the form please email registrar@acfyha.com.
Email address *
Participant Name: *
Your answer
Insurance Company: *
Your answer
Policy Number: *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Emergency Contact Address *
Your answer
Physician's Name *
Your answer
Physician's Phone *
Your answer
Hospital of Choice *
Your answer
Medical History: If the answer to any of the following questions is yes please describe the problem and implications for proper first aid treatment at the end of the form.
Recent tetanus booster?
Taking medications?
Has a doctor placed any restrictions on activity?
Use this section to detail any specifics from above:
Your answer
Parent or Guardian Name (if applicable) *
Your answer
Date *
MM
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DD
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YYYY
A copy of your responses will be emailed to the address you provided.
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