1ST/2ND GRADE BASKETBALL WOODSIDE ATHLETICS PROGRAM CONSENT FORM

AGE AND GRADE OF ATHLETE (SEPARATED BY COMMAS) *

(for example: 11, 5th grade)

FIRST AND LAST NAME OF ATHLETE: *

WINTER SPORT: *

Basketball (Grade 1st/2nd))

Required

GENDER *

MALE

FEMALE

PREFER NOT TO ANSWER

Required

IF JERSEY IS NEEDED, PLEASE INDICATE SIZE:

YOUTH S

YOUTH M

YOUTH L

ADULT S

Other:

EMERGENCY INFORMATION *

Please provide the following information: ALL LEGAL GUARDIAN NAMES, CELL NUMBERS, AND EMAIL

HOME ADDRESS *

EMERGENCY INFORMATION *

Please provide the following information: EMERGENCY CONTACT (NAME AND CELL NUMBER):

MEDICAL INFORMATION: BY TYPING YOUR NAME IN THE SPACE PROVIDED, YOU ARE GIVING AUTHORIZATION OF THE FOLLOWING: *

I give my authorization to my child’s coach or appropriate Woodside School official to approve medical treatment for injuries resulting from either games or practices in the event that either parent or emergency contact cannot be reached. I expect every effort will be made to contact me, my spouse or emergency contact in order to receive my specific authorization before any treatment or hospitalization is undertaken. I understand that in an emergency situation it is not always possible to obtain treatment by our specified physician or hospital. I authorize my child’s coach or appropriate Woodside School official to obtain treatment at the nearest facility if the situation dictates it. Guardian signature needed below:

MEDICAL INFORMATION:

Any medical or physical restrictions the coaching staff should be aware of:

Family Physician (name and phone number): *

Family Hospital (name and phone number): *

Medical Insurance Carrier (name and policy ID number): *

As required by Ed. Code sections 315751-315752

BY TYPING YOUR NAME IN THE SPACE PROVIDED, YOU ARE GIVING AUTHORIZATION OF THE FOLLOWING: *

I give my authorization to my child’s coach or appropriate Woodside School official to approve medical treatment for injuries resulting from either games or practices in the event that either parent or emergency contact cannot be reached. I expect every effort will be made to contact me, my spouse or emergency contact in order to receive my specific authorization before any treatment or hospitalization is undertaken. I understand that in an emergency situation it is not always possible to obtain treatment by our specified physician or hospital. I authorize my child’s coach or appropriate Woodside School official to obtain treatment at the nearest facility if the situation dictates it. Guardian signature needed below: