Cisco Gardens Athletic Association
4328 Jones Rd.
Jacksonville, FL 32220
Authorization for Emergency Care
Participants Name Age
In case of accident or serious illness and the Association is unable to reach me, I hereby authorize
the Association to contact the physician indicated below and to follow their instructions. If it is
possible to contact this physician, the Association may take whatever arrangements are necessary to
provide care and treatment for my child.
In case of an accident or serious illness where immediate treatment of my child is not necessary but
he/she is unable to remain at the Association activity, the coach will contact me to arrange
transportation for my child. If the Association is unable to contact me, I authorize the Association
to contact one of the persons listed below and request them to come to the activity and transport my
Date Parent/Guardian Signature
Sworn to and subscribed before me, this day of 20
My commision expires
Mother & Father/Guardian Name
Father’s Home Phone Cell
Mother’s Home Phone Cell
Physician’s Name Number
Hospital of Choice
Additional persons to be contacted if I am unavailable
Record any known operations, injury or major illness the participant has had in the past 12 months
with approximate dates. Also list known allergies.