Seattle Adaptive Sports Travel Medical Form

Athlete Travel Medical Information Form - Seattle Adaptive Sports
ATHLETE CONTACT INFORMATION
Name*

First NameMiddle NameLast Name
Nickname
Date of Birth (MM/DD/YYYY)*

MonthDayYear
Date
Gender:*

FemaleMaleNon-BinaryPrefer not to AnswerOther
Preferred Pronouns
Address*
City/State/Zip*
Home Phone
Cell Phone
Email
example@example.com
What team(s) do you participate with?*

Seattle Sonics Prep Wheelchair BasketballSeattle Sonics Varsity Wheelchair BasketballSeattle Sonics D2 Wheelchair BasketballPNW Reign Wheelchair BasketballSeattle Sounders Power Wheelchair SoccerSeattle Cobras GoalballSeattle Sled Hockey
EMERGENCY CONTACT INFORMATION
Emergency Contact (if different from Parent/Guardian below)*
Relationship to Athlete*
Home Phone*
Cell Phone*
I am my own guardian*

YesNo
PARENT/GUARDIAN INFORMATION
Relationship to Athlete
Name

First NameLast Name
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Home Phone
Cell Phone
Email
example@example.com
Employer
Employer's Phone
PHYSICIAN INFORMATION
Primary Care Physician
Address

Physician's Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
HEALTH INSURANCE INFORMATION
Health Insurance Provider
Policy Number
Insurance Group ID Number (If Known)
Main Subscriber Name
ATHLETE MEDICAL INFORMATION
Athlete Medical Conditions (check all that apply)

Cerebral PalsyMultiple SclerosisMuscular DystrophyHemiplegiaParaplegiaTetra/QuadriplegiaTransverse MyelitisSpina BifidaLimb AmputationTBISpinal Canal StenosisTraumatic SCINon-Traumatic SCI
Traumatic SCI (Level of Injury)
Non-Traumatic SCI (Level of Injury)
EpilepsyDiabetesAsthmaHeart Condition/StrokeHigh Blood Pressure
Other condition not listed (please specify)
Other Considerations (check any that apply)

DenturesCommunication DeviceGlasses or ContactsHearing AidWheelchairRemovable ProstheticsCrutches or WalkerBraceSplintG-Tube or J-TubeImplanted Device
ColostomyCatheterInhalerEpi-PenInsulin PumpOther
Athlete's Allergies (please list)*

No Known AllergiesLatexInsect Bites or Stings (Type Below):Food (Type Below):Medications
Insect Allergies:
Food Allergies:
Medication Allergies:
Current Medications (includes use of Over the Counter (OTC) medications, birth control, vitamins, and supplements)
Do you have any current chronic or acute infections?*

NoYes
If yes, please describe
Consent to Emergency Medical Care
I understand that this form requests consent from athletes or their parents or guardians for emergency medical care for the athlete if needed in an emergency. In the event of an emergency if I cannot give written or verbal consent for care, unless noted below, it is assumed that I would allow any emergency care deemed necessary by emergency medical providers.

YOU MUST MARK THE BOX AND WRITE YOUR INITIALS NEXT TO ONE STATEMENT TO CONFIRM YOUR INTENT:
I consent to ANY KIND OF MEDICAL TREATMENT, INCLUDING BLOOD TRANSFUSIONS.
INITIALS
I DO NOT consent to BLOOD TRANSFUSIONS, even in a life-threatening emergency. I consent to ALL OTHER KINDS OF EMERGENCY MEDICAL CARE.
INITIALS
Type a question

I DO NOT CONSENT TO ANY KIND OF MEDICAL TREATMENT, EVEN IN A LIFE-THREATENING EMERGENCY.
INITIALS
By signing this form I agree that the coaches or volunteers of Seattle Adaptive Sports can contact emergency medical services on my behalf and the emergency medical providers can provide care for (Type Athlete Name Below) as chosen above in the case of an emergency.*
Athlete First and Last Name
Athlete Signature

Clear
If your screenreader does not allow you to use the signature box above, please type your name in the field below to acknowledge and consent to provision of medical treatment for the athlete named above.
Date*

MonthDayYear
Date
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
This form will only be used in emergency situations. The people who have access to it are the medical volunteers and head coach of your team. Your information will only be shared with emergency medical staff and no others unless you previously give consent for it to be shared.
Should be Empty:

ATHLETE CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

PARENT/GUARDIAN INFORMATION

PHYSICIAN INFORMATION

HEALTH INSURANCE INFORMATION

ATHLETE MEDICAL INFORMATION