Medical Consent Form
ADVERTISEMENT
1MEDICAL CONSENT FORM
TO:
Any Medical Facility/Physician
FROM: _______________________________________________________________
(parent/guardian)
__________________________________________
___________________
(child)
(date of birth)
As the parent/legal guardian of the above named child, who is currently a
registered member of the ______________________________________ team of the
_____________________________________ Soccer League, I hereby authorize
_____________________________________, the team coach, or his designated assistant,
to administer first aid, provide transportation to and from a medical services
provider, and to request and authorize emergency medical treatment for my above
named child while this child is participating in or traveling to/from a team
activity.
This authorization extends inclusively from ______________, 20____
through ______________, 20____.
I assume responsibility for all expenses incurred in the treatment of my above
named child.
Additionally, my child is covered under a secondary coverage policy
through the Louisiana Soccer Association.
_____________________________________
_____________________________________
Parent's Insurance Company Name
Parents Name
_____________________________________
_____________________________________
Policy Number
Home Address
_____________________________________
_____________________________________
Mailing Address
City
State
Zip
_____________________________________
(___)_____________ (___)_____________
City
State
Zip
Home Phone
Work Phone
I hereby hold LSA and any affiliated members free and harmless from any claim of
damage that might arise in the process of providing medical care to my child,
including transportation to and from a medical facility.
________________________________________
_____________________________
Parent's Signature
Date
Sworn to and subscribed before me this ______ day of ________________, 20____.
___________________________________
Notary Public
My commission expires______________.
(raised notary Seal is mandatory)
Revised 8/03
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal