OLY Swimmer's Emergency Form

*Last Name:
*First Name:
*Address:
*City:
*Zip:
*Home Number:
*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:
*Phone Number for Emergency Contact:
*Insurance Company:
*Contract 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.
*Physician's Name:
*Physician Address:
*Physician Phone Number:
*Hospital of Choice:
Does your child have any specific health problems?	Asthma Diabetes Seizure Disorder Heart Condition Severe allergic reactions to- Penicillin Sulfa Other
Does your child have any physical 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)

For questions, contact Nancy Goins, kagoins@aol.com