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®> USA Hockey

Consent To Treat/Medical History Form �

This is to certify that on this date, I l..-8\ Gft rMf?CA:\::flN T . as parent or

guardian of Q \A.{ N's •U:t:\l?vt::te:::Nr . (athlete participant), or for myself as an
adult participant, give my consent to USA Hockey and its medical representative to obtain medical
care from any licensed physician, hospital, or clinic for the above mentioned participant, for any injury
that could arise from participation in USA Hockey sanctioned events.

If said participant is covered by any insurance company, please complete the following:

Insurance Company: :f?h.Ae &o� DI \A.e Sh 1::e( '1
Policy Number: :B �xI\N lo lD3 S 'f 6 3
Parent/Guardian/Adult Participant Signature: ,c Jl&--c-;K. vi; v'-1,1\...,"�r Date: S:-1--,,.,/ r
Excess accident insurance up to $25,000, subject to deductioles, exclusions and certain limitations,
is provided to all USA Hockey registered team participants. For further details visit or
contact USA Hockey at (719) 576-USAH.

Name: �ex-a..\ d w un:e.z Phone: ). 0 � - � l Y- 4 � 3 {
Address: \ s 13 ls \ti OJ? by \Al6� '-5C. c_T
Physician's Name: 'D� � Cfi?.. AlYl Phone: 9 I 4 - -:i. s r - l I ()()
Hospital of Choice: �� lQ;c v(& !ta s't@'7tJ �f){)\AI I cJci

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If the answer to any of the following questions is yes, please describe the problem and its implications
for proper first aid treatment on the back of this form.
O Head Injury D Asthma D Allergies ______
(concussion, skull fracture) D High blood pressure O Diabetes
0 Fainting spells D Kidney problems O Other _______
0 Convulsions/epilepsy 0 Hernia
0 Neck or back injury D Heart murmur
Have you had (or do you currently have) any of the following?
Have you had a recent tetanus booster? GYes O No If yes, when? __________
Are you currently taking any medications? ::l Yes Q!No If yes,please list all medications on back.
Has a doctor placed any restrictions on your activity? CJ Yes ctNo If yes, please explain on back.
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