VALLEY FIGURE SKATING CLUB

SKATER EMERGENCY FORM

This form must be filled out completely and returned with membership packet. Both parent/guardian(s) must sign this emergency form. Thank you.

DATE: ____________________ GRADE: __________________

SKATER’S NAME: ______________________________ DATE OF BIRTH: __________

ADDRESS: _________________________________________________________________________

Address (City) (zip)

TELEPHONE NUMBER: _____________________ ALTERNATE NUMBER: ___________

EMAIL ADDRESS: ___________________________________________________________________

FATHER’S PLACE OF EMPLOYMENT: ________________ PHONE: __________________

MOTHER’S PLACE OF EMPLOYMENT: _______________ PHONE: __________________

IF PARENT CANNOT BE REACHED, NAME OF RELATIVE OR FRIEND WHO WILL ASSUME TEMPORARY CARE OF YOUR CHILD:

#1

NAME: _______________________________ RELATIONSHIP: _________________________

ADDRESS: _____________________________________________ PHONE: __________________

#2

NAME: _______________________________ RELATIONSHIP: _________________________

ADDRESS: _____________________________________________ PHONE: __________________

HEATH INFORMATION:

Please list any serious illnesses, severe allergies, or chronic conditions: __________________________

Any medications?: ____________________________________________________________________

INSURANCE INFORMATION

MEDICAL INSURANCE: ________________________ INSURANCE #: _____________________

DENTAL INSURANCE: ________________________ INSURANCE #: _____________________

HOSPITAL PREFERENCE: ______________________________________________________________

DOCTOR: _____________________________________ OFFICE PHONE: ____________________

DENTIST: _____________________________________ OFFICE PHONE: ____________________

I/We, the undersigned, do hereby authorize Valley Figure Skating Club to call an emergency ambulance in case of accident or acute illness and to arrange for necessary emergency medical and surgical care in case I/We am not immediately available. Any qualified physician called by Valley Figure Skating Club may treat and do whatever is necessary for the health and well being of my child.

It is understood that a conscientious effort will be made to notify me/us (parent/guardian(s)) before such action will be taken. In the event that I/We cannot be contacted, Valley Figure Skating Club Board Members are hereby authorized to take whatever action is deemed necessary in their judgment for the health and well being of my/our child.

I/We will not hold Valley Figure Skating Club financially responsible for the emergency care and/or transportation of said child.

______________________________ ________________________________ _________________________

Parent/Guardian Parent/Guardian Date 05/30/08