Consent For Treatment Form

All form fields are required.

Please note: This information is kept in an encrypted file with ACES Diving Staff. For the safety of all our divers, please complete all information accurately and completely. In the event of an emergency, this information is available to medical personnel.

Athlete Information


First Name:
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Last Name:
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Date Of Birth:
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E-Mail:
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Address:
Street:
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City:
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State:
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Zip Code:
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Parent/Guardian:
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Work Phone:
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Home Phone:
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Cell Phone:
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"I, the undersigned, as the parent or legal guardian of a minor, hereby authorize such diagnosis, medical treatment or surgical procedures as may be considered appropriate under the circumstances for the treatment of any injury or illness of the minor. ACESDiving, its coaches or employees, or any facilities associated with ACESDiving, shall not be responsible in any way for any consequences from said diagnostic, medical or surgical treatment and are hereby released from any and all claims and causes of actions that may arise, grow out of or be incident to any diagnosis, treatment or surgery in so far as the law allows provided that these services are preformed with ordinary care and to the best of their ability."

Please make a selection. By checking this box and typing your name, you confirm that you have read and agree to be bound by the terms and conditions as outlined in the ACESDiving “consent for treatment” form above and confirm that your electronic signature is the legal equivalent of your hand written signature.

Enter Signature:
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Enter Date:
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Health Insurance Name:
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Phone Number:
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ID or Contract Number:
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Policy or Group Number:
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Policy Holder's Name:
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Policy Holder's Date of Birth:
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Physician’s Name:
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Physician's Number:
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Current medications:
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Known Allergies, handicaps or limitations:
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Emergency Contact #1


Name:
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Phone Number:
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Relationship:
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Emergency Contact #2


Name:
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Phone Number:
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Relationship:
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