Babylon Soccer Club Emergency Medical Treatment Consent Form
Babylon Soccer Club is a 501(c)3 Organization
EIN 11-3297897
PLAYER INFORMATION
Please fill in a separate entry for each child. All form fields are required.
Team Name *
Player First Name *
Your answer
Player Last Name *
Your answer
Player Date of Birth *
Your answer
Parent/Guardian Name(s) *
Your answer
Home Address *
Your answer
Home Phone(s) *
Your answer
Cell Phone(s) *
Your answer
Medical Conditions / Allergies / Concerns (type none if there are none to list) *
Your answer
PHYSICIAN INFORMATION
Physician Name *
Your answer
Physician Phone *
Your answer
Physician Address *
Your answer
Health Insurance Company *
Your answer
Health Insurance Policy # *
Your answer
EMERGENCY CONTACT(S)
Please list at least 1 emergency contact for the league or coach to contact in the case that you (the parent or guardian) are not available.
Full Name *
Your answer
Relation to Player *
Your answer
Address *
Your answer
Phone Number *
Your answer
CONSENT
By typing your name in the space below, as the parent or guardian of the above player, you hereby grant your consent, in the event of injury or sickness, to the emergency medical diagnosis and treatment of your child deemed necessary by the attending physician or other attending licensed qualified medical professional.
Signature (Type Your Full Name) *
Your answer
Email Address for Form Confirmation *
Your answer
Submit
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