MEDICAL INFORMATION Medical Form Date * Athletes’ Name: * Athletes’ Name: Last Last First First Middle Middle Date of Birth * Sex MaleFemale Home Address: * Mothers’ Name: * Mothers’ Phone No: * Fathers’ Name: * Fathers’ Phone No: * Parents’ Email address: * If parents cannot be reached, person to contact in case of emergency: Name: * Phone No: * Relation: * Physicians Name and Phone Number: * Hospital Preference: * Does athlete take medications on a daily basis? No Yes If yes, specify Known Allergies: Does athlete have a health condition requiring possible emergency care? No Yes If yes, specify I authorize UUA to administer first aid and/or take my child * to a physician or hospital for emergency treatment in the event it appears necessary and neither parent (guardian) can be contacted. I authorize UUA to contact ambulance/emergency services in the event it appears Child Name: * Signature of parent (guardian): * Date * Submit If you are human, leave this field blank.
