NEW HOLLAND SWIM TEAM EMERGENCY MEDICAL WAIVER 
NAME __________________________ HOME PHONE NO. _________________ CELL PHONE________________
DOES YOUR CHILD HAVE ANY CHRONIC ILLNESS? _____YES _____NO IF YES, EXPLAIN 
IS YOUR CHILD CURRENTLY ON ANY MEDICATION? _____YES _____ NO IF YES, EXPLAIN 
DOES YOUR CHILD HAVE ANY ALLERGIES? _____ YES _____ NO IF YES, EXPLAIN 
HAS YOUR CHILD HAD A TETANUS INJECTION? _____ YES _____ NO       DATE OF LAST SHOT 
IN CASE OF EMERGENCY ROOM CARE PLEASE PROVIDE THE FOLLOWING: 
INSURANCE POLICY NUMBER: _______________________ 
NAME OF INSURANCE COMPANY OF THE INSURED: _________________________ 
IN CASE OF MEDICAL EMERGENCY, I UNDERSTAND EVERY EFFORT WILL BE MADE TO CONTACT PARENTS OR GUARDIAN OF THE CHILD. IN THE EVENT I CANNOT BE REACHED, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED TO HOSPITALIZE, SECURE PROPER TREATMENT, AND TO ORDER INJECTION, ANESTHESIA OR SURGERY FOR MY CHILD AS NAMED ABOVE.
FAMILY PHYSICIAN NAME & ADDRESS:_______________________________________________ 
FAMILY PHYSICIAN PHONE NUMBER:________________________________________________ 
DATE SIGNATURE OF PARENT OR LEGAL GUARDIAN 
DATE:_____________________	SIGNATURE:_______________________________________
Emergency Contact (other than parent)________________________________ Phone ________________