Medical Care Authorization Form
| Swimmer's Name: |
Age: |
Birth Date: |
| Address: |
| City: |
State: |
Zip: |
Medical History: (allergies, injuries, asthma, disabilities, etc.)
| Medications currently using: |
| Physician: |
Telephone: |
| Dentist: |
Telephone: |
| Insurance: |
Policy #: |
Emergency Contact: (Other than Parents or Guardian)
| Name: |
Relationship: |
Telephone: |
| 1. |
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| 2. |
|
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| 3. |
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Medical Waiver:
In our absence, or the absence of the aforementioned emergency contacts, the Dekalb Aquatics coaching staff has our authority to administer medication, first aid, or any other medical treatment deemed necessary. |
| Parent or Guardian Signature: |
Date: |
General Waiver:
I agree to waive, release, and forever discharge any and all rights and claims for any injuries or damages that can occur during practice, travel, and competition from DeKalb Aquatics Swim Team, Incorporated, a Georgia nonprofit corporation, and it’s coaching staff that USA swimming will not cover. |
| Parent or Guardian Signature: |
Date: |
