Consent Form

For those who dont have a consent form you must copy and paste this into some type of Word document and print+fill this out before you can practice, along with a copy of your insurance card. Thank you.

PIUS Girls Rugby
2008-2009 REGISTRATION FORM
Name: ______________________________ Grade: _____
Parent name(s) ______________________________
Other Sports Played @Pius:_____________________________________
Player Email: ______________________________ ____________________
Parent Email: ______________________________
Circle Rugby Season(s) to play: spring / fall
Player Cell #: ______________________________
Parent Cell #: ______________________________

----------------------------------Consent to Medical Treatment for Minor-------------------------
In connection with _____________________________’s (insert full name) participation in the Pius Girls Rugby team, I authorize any accompanying adult bringing my daughter
to a treatment facility to consent to emergency medical treatment on the advice of a physician when the need for such treatment is immediate, and when efforts to contact me are unsuccessful. Valid for all team related activities from today’s date until the end of the 2008-2009 school year and summer session. I also hereby state that I have legal custody over the minor athlete listed below and that the athlete has medical insurance coverage of at least $100,000.
Athlete’s Name: _____________________________
Parent/Guardian’s signature: ______________________________
Date: ___________
Emergency Medical Information
Emergency Contact Person: Phone #:
Insurance Provider: Group #:
Family Doctor: Membership #:
-Medications Student is currently taking:
-Known allergies:
-Previous injuries or medical conditions relevant to athletic participation (asthma, etc.):