EMN Emergency Contact Information

Beginning this season (2021-2022) EMN is allowing families to enter their athlete emergency contact information into a secure web form.

This web form may also be used for non-registered skiers who attend certain EMN-sponsored activities (such as summer camp). Coaches and other adults who attend certain EMN-sponsored activities (especially with an overnight component) might also be asked to complete this form.

Families who are not comfortable entering this information online may continue to use the existing printable form.

Click this link to use the printable EMN Contact Information and Release Form.

Or, begin entering your information into the secure EMN Emergency Contact Information Form below.

Note that you must complete one form for each registering skier. You may ignore references to parent “location during camp” for regular registration.

Athlete Emergency Contact Information and Release

This form allows you to enter required emergency contact information for a registered skier. This information can only be accessed by a small number of coaching, medical, and management team members of EMN Juniors. It is not available to the general club or the full coaching team nor is it shared with anyone outside EMN, except in the case of a medical emergency. If you are not comfortable submitting this information here, you may complete and return a copy of the physical form located here: EMN Contact Information and Release Form

Athlete Information

Athlete First Name *

Athlete Last Name *

Date of Birth *

Athlete Age *

Athlete Gender *

Athlete Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Athlete Cell Phone

Athlete Email

Confirm Email

Parent/Guardian Contact Information (include location during camp session)

Parent/Guardian 1 Name *

P/G 1 Address Needed?

Check if same address as Athlete

Parent/Guardian 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 1 Phone

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Email *

Parent/Guardian 1 Location/Phone During Camp if different:

Parent/Guardian 2 Name *

P/G 2 Address Needed?

Check if same address for Parent/Guardian 2

Parent/Guardian 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian 2 Phone

Parent/Guardian 2 Cell Phone *

Parent/Guardian 2 Email *

Parent/Guardian 2 Location/Phone During Camp if different:

Emergency Contacts (Please provide 2)

Emergency Contact 1 *

Name

Contact1 Relationship *

Relationship

Contact1 Phone *

Phone

Emergency Contact 2 *

Name

Contact2 Relationship *

Relationship

Contact1 Phone (copy) *

Phone

Insurance Information

Family Health Insurer *

Include insurer name and address.

Insurer Phone Number *

Policy Number *

Family Physician *

Physician Phone Number *

Family Dentist *

Dentist Phone Number *

Consent for Medical Treatment for a Minor (one form per child)

As parent or legal guardian I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or the well being of my dependent. “I understand that the directors and coaches of Eastern Massachusetts Nordic (EMN) or anyone associated with the sites EMN runs activities at, their trustees, agents and officers, will not assume responsibility for accidents and medical or dental expenses incurred as a result of participation in this program. The applicant is covered by our family insurance, is in good health, and able to participate in the physical activity of a vigorous program. I hereby authorize the EMN directors to act for me according to their best judgment in any emergency requiring medical attention in the event that I and my emergency contacts cannot be reached. I will hold harmless EMN, and any other site used by EMN, their trustees, agents and officers, of any and all liability actions, causes of action, claims and demands of every kind and nature whatsoever which may arise in connection either with or resulting from participation in any of their activities.”

Medical *

I certify that no significant health problems have occurred since last exam on:

(date of last physical) *

Electronic Signature *

By checking this box I affirm that (1) I am the parent or guardian of the skier on this registration, (2) I have read and understood this document and (3) I accept that this will be used as a valid electronic signature.

Name *

Date *

Message

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