MEDICAL RELEASE FORM

This form must be completed for all minor competitors not accompanied by a parent or guardian. Send with entry form or deliver to registration desk prior to taking the ice for practice or competition.

(Please type or print clearly)

Name of Competitor _________________________________________ USFSA # _______________________

In case of an emergency, I hereby authorize medical treatment for my child, as named above, while participating in the 1999 CCIA Novice/Advanced Competition.

Printed Name of Parent or Guardian_____________________________________Date_______________________

Signature of Parent or Guardian____________________________________________________________________

EMERGENCY NOTIFICATION INSTRUCTIONS

Name of Person to Contact:_______________________________________________________________________

Relationship:__________________________________________________________________________________

Day Telephone Number:_________________________________________________________________________

Night Telephone Number:________________________________________________________________________

DRUG ALLERGIES AND SENSITIVITIES

List drug allergies and sensitivities. If you have none please write “NONE”

_____________________________________________________________________________________________

MEDICAL CONDITIONS AND SPECIAL INSTRUCTIONS

List any existing medical conditions or special care needs. If you have none write “NONE”.

______________________________________________________________________________

_____________________________________________________________________________________________

Physician’s Name:______________________________________________________________________________

Physician’s Office Telephone Number:_________________________________________

Physician’s Emergency Telephone Number : ___________________________________