Medical Release Form (Sample )

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MEDICAL RELEASE FORM
I hereby give my permission for any and all medical attention necessary to be
administrated to my child,
(Name) ______________________________________________________
in the event of an accident, injury, sickness, etc., under the direction of the persons listed
below, until such time as I may be contacted. I assume all financial responsibilities for
any expenses incurred.
My Name: ____________________________________________________
My Address: ___________________________________________________
Home Phone: ____________________ Work Phone ____________________
My Insurance company:_________________________ Policy # _______________
In the event I cannot be reached, any of the following people may be designated to act in
my behalf:
1.
Coach:____________________________________
2. Assistant Coach ________________________________
3. Team Manager _________________________________
4. Other:_______________________________________________________________
Physician’s Name:_______________________________ Phone # ________________
Address: _____________________________________________________________
I understand and accept that the risk of injury is possible while participating in athletic activities. I authorize
the directors and staff of Fore Kicks to act according to their best judgment in any emergency requiring
medical attention. I agree to indemnify and hold harmless anyone associated with Fore Kicks for all medical
or dental expenses incurred as a result of participation in Fore Kicks activities or programs, or use of Fore
Kicks facilities. I hereby acknowledge that Fore Kicks Sports Complex, its staff, referees or representatives,
cannot be held responsible for any injury to my son/daughter.
Signature
(Parent/Guardian)________________________________Date:_______________

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