With my signature, as parent or legal guardian, I give authority to the coaches listed below to

oversee the medical treatment in the event of an accident, injury or sickness with respect to my child

(named below) until such time as I can be contacted. I also assume full responsibility for payment of any and all medical treatment provided to my child.

Child’s Name: _________________________________________________________

Parent / Guardian: Name:___________________________________________________

Address: _____________________________________________________________

Home Phone: _____________ Work Phone: _____________ Cell:_______________

Insurance Co. ________________________ Policy # ___________________________

Participant’s Physician ____________________________________________________________

Physician’s Address ____________________________________________________________

Physician’s Phone ________________________________________

Participant’s Known Allergies / Medical Conditions ________________________________________________________________________________________________________________________________________________

________________________________________________________________________

In case a parent / guardian cannot be reached, one of the following is designated to oversee the medical treatment until such time as a parent / guardian can be contacted.

Coach’s name: Angie Sieber______ Phone # (717)626-0481

Coach’s name: Dwayne Arehart Phone # (717)626-2298

Other’s name: Curt McCracken Phone # (717) 627-2240

Parent / Guardian Signature: ________________________________ Date: __________

Notary Seal

Notary Signature_________________________________