Welcome to Michigan Cyclones Lacrosse.

Forms

Medical Treatment Form

Name of Minor:	*required
Relationship to You:	*required
Name of Parent/Guardian:	*required (As a Parent/Guardian, I do hereby authorize the treatment by qualified and licensed Physician of any conditions which, in the opinion of the physician, is deemed necessary and appropriate. This authorization is granted only after a reasonable effort as been made to reach me.)
Name of Parent/Guardian:	Yes No
Emergency Phone Numbers:	*required
Family Physician:	*required
Physician Address:
Physician Phone:

	List of allergies, medication, contacts or other pertinent information:


	Health Insurance Co., Group and Policy or Contract Numbers:


Date:	*required