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Printable PDF Version To Mail (for Non-players)

I, _________________________________, 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.

In 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.

I, 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.

Signature: ____________________________________  Date: _________________

Medications currently being taken: ________________________________________

_____________________________________________________________________

Allergies to any foods or medications? Please list: ___________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Describe any recent injury (sprain, strain, fracture, or concussion) and/or surgery within the past 3 years.

_____________________________________________________________________

_____________________________________________________________________

Describe any recent (within the past 5 years) serious medical illnesses (such as heat stroke, heat exhaustion, diabetes, heart murmur, etc.):

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

Are you taking any herbal alternative medications? If yes, what are they?

____________________________________________________________________

In case of emergency, please notify: ______________________________________ 

Telephone: (_______)____________________   Relation:_____________________

Medical/Accident Insurance Carrier: ______________________________________

Policy Number: _______________________________________________________ 

 


Coast to Coast Amateur Athletics * P.O. Box 389 * Marietta, OH 45750
PHONE 928-854-9455 * FAX 928-854-6669

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