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ALUMNI LISTING:
Where Are They Now?

 
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Printable PDF Version To Mail (for Players)

I, __________________________the parent/guardian of _________________________ a minor, have entrusted such minor into the care of Coast to Coast Amateur Athletics, Inc., team coaches or medical trainers, all adults, for that period of time that such minor is a member of said Coast to Coast Amateur Athletics, Inc. program.

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 surgeon: or to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to such a minor by a dentist. 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 and I, as such minorís parent would have to consider.

As the parent of such minor, on behalf of him and his 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 such minor may have as a result of the exercise by the tour leader of the authorization granted herein.

Parent/Guardian Signature: _______________________________ Date: _____________

Medications currently being taken (What for?): _________________________________

______________________________________________________________________

Allergies to any food(s) 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.):

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Is your child taking any herbal alternative medications (what are they?): _______________

_____________________________________________________________________

_____________________________________________________________________

In case of emergency, please notify: _________________________________________ 

Telephone: (_______) __________________≠≠≠≠______________________________ 

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