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Newtown Middle School Athletics

Consent To Treat Form

 

Athlete:  ________________  Sport:  ________________

 

In case of Emergency, I __________________________ give permission for my son/daughter to be treated by medical personnel on site at a school sporting event.

Parent CELL 1 ________________

Parent CELL 2 ________________

Day time phone number  _______________________

Home phone number  _____________________

Person to contact if unavailable:  _________________   

Contact’s phone number:  __________________

My son/daughter suffers from (please circle any):

Allergies:  _______________________________________

Asthma?  Yes   No   

Inhaler?  Yes   No    

Daily meds? Yes    No

Diabetes?  Yes    No     

Insulin   Yes    No

Seizures?   Yes    No     

Medication?  _____________________

Other medical conditions:  _______________________________________

Any daily medications:  _________________________________________

_____________________________________________________________

Preferred Hospital:  _____________  

Insurance Company:  _____________

Card holder:  __________________  

ID#:  _________________________

Parent Signature:  ________________________

Date:  ______________