I hereby give my permission for any and all medical attention necessary to be administered to my child in the event of an accident, injury, sickness, etc. under the direction of the pool manager or swim team coaches or their designated staff until such time as I may be contacted.   

Name of Minor: __________________________________  Date of Birth: _________________

Known Allergies: ______________________________________________________________

Date of Last Tetanus shot: ________________________

Special conditions or illnesses: ___________________________________________________

____________________________________________________________________________

Medications presently being taken:  _______________________________________________ 

Insurance Company:  __________________________________________________________

Policy Number: __________________________

Physician’s Name: ________________________Telephone No.: ________________________

Dentist’s Name: __________________________Telephone No.:  ________________________ 

Signature of Parent or Legal Guardian: _____________________________________________

Date Signed: _____________________

Parent/Guardian Address: _______________________________________________________

Telephone Numbers:     Home #: _____________________ Work #: _____________________

                                        Cell #: _____________________

Witness to Parent or Legal Guardian Signature  ___________________________________        

Date Witnessed: __________________