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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
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
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Address
Hospital of Choice
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.
Head Injury (Concussion, Skull Fracture
Neck or Back Injury
High Blood Pressure
Allergies (please list at the end of the form)
Other (Please list at the end of the form)
Recent tetanus booster?
Yes (Please list all medications at the end of the form)
Has a doctor placed any restrictions on activity?
Yes (Please explain at the end of the form)
Use this section to detail any specifics from above:
Parent or Guardian Name (if applicable)
A copy of your responses will be emailed to the address you provided.
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