PDF Version To Mail (for Non-players)
_________________________________, as a traveling member of the Coast to Coast
Amateur Athletics, Inc. program to _________________________________ (destination)
hereby authorize Coast to Coast Amateur Athletics, Inc., team coaches and all
adult personnel to take whatever measures are reasonably necessary for my care
in the event of a medical emergency.
such connection, I authorize such caring adult to consent to any X-ray examination,
anesthetic, medical or surgical diagnosis or treatment, and supervision; and on
the advice of a physician and/or surgeon to consent to any X-ray examination,
anesthetic, dental or surgical diagnosis or treatment and hospital care to be
rendered to myself by medical personnel. If, on any occasion, such consent is
rendered for any such medical or dental attention, it is to be considered under
the same kind of circumstances, within the full discretion, and in the course
of the same kind of responsible deliberation that I would have to consider.
on behalf of my heirs, executors or administrators, and assigns, I hereby discharge
Coast to Coast Amateur Athletics, Inc. its assigns and successors, from all rights,
claims, and actions which may arise as a result of the exercise by the tour leader
of the authorization granted herein.
currently being taken: ________________________________________
to any foods or medications? Please list: ___________________________
any recent injury (sprain, strain, fracture, or concussion) and/or surgery within
the past 3 years.
any recent (within the past 5 years) serious medical illnesses (such as heat stroke,
heat exhaustion, diabetes, heart murmur, etc.):
you taking any herbal alternative medications? If yes, what are they?
case of emergency, please notify: ______________________________________
Insurance Carrier: ______________________________________