Consent to Treat Form

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This is to certify that on this date below, I as parent or guardian of athlete participant below, give my consent to Meadville Wrestling 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 wrestling events. If said participant is covered by any insurance company, please complete the following:

Name of Insurance Company:

Policy Number:

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Medical Information

Wrestler Name:

Address:

Birth date

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Who to contact in case of an emergency?

Name:

Relationship

Daytime Phone:

Evening Phone:

Physician's Name:

Phone Number:

Health Problems that we need to be aware of?

Allergies?

List ANY medications:

Signature of Parent/Guardian

CONSENT TO TREAT FORM

CONTACT US: