AYHA - Consent to Treat Form

This is to certify that on this date, I * as parent

or guardian of * (athlete participant), or for

myself as an adult participant, give my consent to USA Hockey 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 USA Hockey sanctioned

events.

If said participant is covered by any insurance company, please complete the following:

Insurance Company *

Address, City, State, Zip (of Insurance Company) *

Policy Number *

Relationship to Athlete *

Home Address, City, State, Zip *

Phone *

Date *

Excess accident insurance up to $25,000, subject to deductibles, exclusions and certain
limitations, is provided to all USA Hockey registered team participants. For further details
visit www.usahockey.com or call USA Hockey at 719-576-USAH.

Signature (Type your name here) *

Email Address * (Copy of this form will be sent here.)