USA Hockey Consent To Treat


USA Hockey
Consent To Treat/Medical History Form

This is to certify that on this date, I , as parent or guardian of  , (athlete participant), or for myself as an adult participant, give my consent to USA Hockey and its medical representative to obtain medical care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury that could arise from participation in USAHockey sanctioned events.

If said participant is covered by any insurance company, please complete the following:
Insurance Company:

Policy Number:  

Excess accident insurance up to $25,000, subject to deductibles, exclusions and certain limitations,is provided to all USA Hockey registered team participants. For further details visit usahockey.com orcontact USA Hockey at (719) 576-USAH.

EMERGENCY CONTACT

Name:           Phone:
Address:
Physician’s Name:  .  Phone:  
Hospital of Choice:  

COMPLETION OF MEDICAL HISTORY INFORMATION BELOW IS OPTIONAL

MEDICAL HISTORY

If the answer to any of the following questions is yes, please describe the problem and its implicationsfor proper first aid treatment on the back of this form.

[Have you had (or do you currently have) any of the following?

Condition:

Have you had any other condition not listed above?:

Have you had a recent tetanus booster?   

If yes, when?

Are you currently taking any medications?  

If yes, please list all medications:    

Has a doctor placed any restrictions on your activity?     

If yes, please explain:  
Signature Date  :August 12, 2022

Leave this empty:

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Signature Certificate
Document name: USA Hockey Consent To Treat
lock iconUnique Document ID: 7735794b4daea16ff8978ab6c7e292b2d4f451c0
Timestamp Audit
October 15, 2021 4:11 pm EDTUSA Hockey Consent To Treat Uploaded by Dennis Franczak - dfranczak@bostonimperials.com IP 71.192.200.18