Medical Information Form

LLOYDMINSTER MINOR FOOTBALL ASSOCIATION
2023 MEDICAL INFORMATION FORM

2023 RELEASE AND INDEMNITY FORM

2023 CONSENT FORM

First Name *

Last Name

Parent/Guardian Name #1

Phone number:

Parent/Guardian Name #2

Phone number:

Name of emergency contact:

Phone number of emergency contact:

Medications:

Allergies:

Medical conditions/recent injuries:

Physician's Name:

Physician Phone Number:

Dentist Name:

Dentist Phone Number:

Please give details below if you answered yes to any of the previous questions:

Your physician should check any medical condition or injury problem before participating in a football program. I understand that it is my responsibility to keep the team management advised of any change in the above information as soon as possible and that in the event no one can be contacted; team management will take my child to a hospital or M.D., if deemed necessary. I hereby authorize the physician and nursing staff to undertake examination, investigation, and necessary treatment of my child. I also authorize release of information to appropriate people (coach, assistant coach, manager, and physician) as deemed necessary with my child.

Date of signing:

I/We release and agree to hold harmless and indemnity the Lloydminster Minor Football Association (LMFA), its members, sponsors, and officials, from all claims arising from the risks and hazards incidental to or arising from our child’s participation in the activities of the LMFA, including any claims arising from any injury suffered by:

Date of signing:

I/We consent to our child participating in the activities of the LMFA and we consent to the LMFA publishing photographs of our child and disclosing our child’s name for purposes incidental to the activities of the LMFA.

Date of signing:

Please check the appropriate response below pertaining to your child: