| Fulton-Montgomery Community College Fencing Club - Minor Treatment Form | ||
| Name of Minor- | Birthdate - | |
| Insurance Company - | ||
| Policy Number or Group Number - | Social Security Number - | |
| MEDICAL INFORMATION - | ||
| Allergic Reactions - | ||
| Current Medications - | ||
| Last Tetanus Shot - | ||
| Other relevant information if treatment is necessary - | ||
| EMERGENCY PHONE NUMBERS - | ||
| Father - Home -
Father - Work - |
Mother - Home -
Mother - Work - | |
| Number to call if parents cannot be reached - | ||
| PLEASE CHECK ONE OF THE FOLLOWING OPTIONS AND SIGN - | ||
| ______ I grant permission of Michael McDarby or an adult designated by him to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that if a serious medical problem should arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such treatment as deemed necessary (including surgery, X-ray examinations and anesthesia to be rendered to said minor by a licenced physician or nurse). | ||
| ______ I authorize limited care as follows: | ||
| Full name of father - | ||
| Full name of mother - | ||
| I, ____________________________________________, declare that I am the Father / Mother / Guardian
of the above named minor (circle the correct title).
_______________________________________ __________________________ | ||