ESDAA Tournament Medical Form
_____________________________ Age: _________ DOB: ____________
Home Phone: ________________________ Work Phone:
Contact: ___________ Phone:
Describe any physical/medical issues: (ie.: seizures, diabetes, etc.)
Date of last tetanus shot: ___________________________
any allergies to food or medication:
List any medication to be given. Include the drug, dosage and reason for medication. (Also, please fill out the attached medication permission form(s).)
Private Physicians' Name: ____________________ Phone: ________________
Medical Insurance Co: ________________________
Medical / Medicaid Insurance Policy Number: ________________________
Medical Insurance Policy Holder: ________________________
I,___________________________, hereby give permission for my child to receive medical treatment at any time due to an emergency while present at the ___________________________(school name), in ________________________ (city/state) on _____________ (date).
I accept all responsibility for medical, hospitalization, and liability that may arise from this tournament. I understand that any charges incurred for such treatment are responsibility and agree to pay for any such charges not covered by my insurance.
Parent/Guardians' Signature: ____________________________________ Date: