OLY Swimmer's Emergency Form
Last Name
|
First Name
|
Address
|
City
|
Zip Code
|
Home Phone
|
Mother's Name
|
Mother's Work Phone
|
Mother's Cell Phone
|
Father's Name
|
Father's Work Phone
|
Father's Cell Phone
|
Emergency Contact Name
|
Relationship to Emergency Contact
|
Emergency Contact Phone Number
|
Insurance Company
|
Ccontract Number
|
Group Number
In case of accident or serious illness, I
request that OLY contact one of the persons listed above. If OLY is
unable to reach such persons, I hereby authorize OLY to call the physician
indicated below. If it is impossible to contact this physician, OLY
may make the necessary emergency arrangements. Any obligation for
medical expenses resulting from treatment in such a case will be handled
by said parent or guardian. |
Physcian's Name
|
Physcian's Address
|
Physcian's Phone Number
|
Hospital of Choice
|
| Does your child have any specific health problems?
Asthma
Diabetes
Heart Condition
Seizure Disorder |
| Does your child have any severe allergic reactions to
Sulfa
Penicillin |
Does your child have any physcial restrictions? Please Describe
By filling out my name and date I confirm
that all of the above information is correct and if any changes occur I
will fill out a new form. I will sign this officially at the
mandatory parent meeting or by working out a time with my group rep. OLY has permission to keep this form on
file at the pool. |
Name
|
Date
___________________________________
Signature (to be signed at parent meeting or with group rep) |
|