EMERGENCY CONTACT INFORMATION AND PARENTAL CONSENT FORM

HELENA DYNAMOS JUNIOR CYCLING TEAM 2016SEASON

Rider Name
Address
Rider Email (if any)
Daily E-mail Address:
Home phone
Father name
Father work phone
Father cell phone
Father Email
Mother name
Mother work phone
Mother cell phone
Mother Email
Rider Jersey Size
Rider Cell number
Rider Grade/School
Rider Cycling Experience
Rider Insurance policy / (Required)
Rider Physician and phone number

This information is being collected only so that we may become aware of any existing medical condition that your child may have and so that we can act according should a medical emergency arise. All information will be kept confidential.

RISK MANAGEMENT: There are inherent risks associated with cycling. We do everything we can do to manage those risks and keep your child safe as possible. However, due to these inherent risks, there is the possibility that your child could be mildly or seriously injured while participating in our program.

Please circle if your child suffers from any of the following:

(please attach information if you answer YES to any question)

Chronic or recurrent illnessY / N

Dental braces, platesY / N

Diabetes Y / N

Dizzy Spells Y / N

Heart Condition Y / N

Epilepsy Y / N

Blackouts Y / N

Travel Sickness Y / N

Eyeglass or contacts Y / N

Chest Pain w/ exerciseY / N

Asthma Y / N

Migraine Y / N

Heart murmur Y / N

Short of breath after running Y / N

Respiratory condition Y / N

Knee, ankle or neck injuries Y / N

Allergies

Penicillin Y / N

Aspirin Y / N

Any drugs Y / N ______

Any foods Y / N ______

Is your child current on tetanus immunization Y / N

Is your child presently taking any drug or medication, or under any type of treatment or have any condition of physical disability or current injury which may prevent full involvement in practice and games? Y / N

IMPORTANT: If you answered YES to any of the above, please provide any necessary details.

PERMISSION IS GIVEN FOR THE FOLLOWING (Phone call will be made to parents and/or emergency contacts):

  • COACHES ARE TO CALL AN AMBULANCE IF NECESSARY
  • COACHES ARE ALLOWED TO TAKE MY CHILD TO A PHYSICIAN OR HOSPITAL

I hereby give my consent for my son/daughter to participate in this program. I understand that my child will be cycling outdoors on primarily public roads and lands near Helena. While every step is taken to insure the safety of my child, I understand that the Helena Dynamos cannot be responsible for accident, injury, or loss incurred as a result of these outings.

Parent / Guardian SignatureDate:

Rider SignatureDate:

PARENTS WILL BE CONTACTED IMMEDIATELY IN CASE OF EMERGENCY. IN THE EVENT WE ARE UNABLE TO CONTACT YOU, WE WILL CONTACT THE EMERGENCY CONTACT PERSON.

Rider Tag: The purpose of this tag is to provide us with the most critical information immediately in case there is an accident. Please cut out and use clear packing tape to attach it to your seat post.

Please remember that riding a bike is inherently dangerous. There is a chance of injury or death.

In case of an emergency, parents will be contacted immediately. In the event we are unable to contact parents we will contact the emergency contact listed above. If parents and emergency contact cannot be reached, we will call 911.