Medical Release Form
Download a blank fillable Medical Release Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1MEDICAL RELEASE FORM
As the parent/legal guardian of:
Name of Player:
I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request
and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed
technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above
minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to
dispose of any specimen or tissue taken from the above-named player.
Date of players birth:
Date of last Tetanus Booster:
Allergies:
Other Medical Conditions:
Player's Physician:
Phone #:
(
)
-
Name of Parent/Guardian:
Street Address:
City:
State:
TX
Zip Code:
Phone # H:
(
)
-
Work #:
(
)
-
Person responsible for charges
(if different from above)
Street Address:
City:
State:
TX
Zip Code:
Phone # H: (
)
-
Work #:
(
)
-
Person to notify if parent/guardian is unavailable:
Street Address:
City:
State:
Zip Code:
Phone # H:
(
)
-
Work #:
(
)
-
(
)
-
Medical and/or Hospital Insurance Co
Phone #:
Policy Holder
Policy Number
Signature of Parent /Guardian:
Date:
Sworn to and subscribed before me on the
day of
, Yr
Notary Public
My Commission expires
U S YOUTH SOCCER/NORTH TEXAS SOCCER
REVISED 09/99
12
NORTH TEXAS SOCCER/Registrar's Manual/ 09-99
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal