BU Boys' Soccer Medical Consent Form

Medical Insurance Information

Insurance Company: ___________________________

Primary Insurance Holder’s Name:____________________

Primary Insurance Holder's Date of Birth:_____________

ID Number: _______________________

Group Number: _____________________

Plan Number: _______________________

Primary Physician's Name:_______________________________

Primary Physician's Phone Number:________________________

Important Medical Information: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Emergency Contact Information

Parents'/Legal Guardians' Names: ___________________________

Home Phone Number:_________________

Father's Cell Phone Number:_________________

Mother's Cell Phone Number:________________

Secondary Emergency Contact:_____________________

Home Phone Number:____________________

Cell Phone Number:_____________________

Relationship to Athlete:______________________

I authorize BU leaders, coaches, administrators and/or parent volunteers to act as an agent for me,if they are unable to reach me, to consent to any emergency medical treatment necessary either at a doctor’s office or hospital.

Parent/Legal Guardian(please print):__________________________

Signature:___________________________________Date:____________