Mt. Olive Jr. Marauders Football Medical Release Form printable pdf download

Mt. Olive Jr. Marauders Football

Medical Release Form

Your child may not be treated, even in the event of an emergency situation, except when, in the opinion of the attending

physician, a life is in the balance. Written consent of a parent and/or guardian is required, for all treatment given, in any

hospital’s emergency room, for unmarried minors, except in cases of extreme emergency.

Grandparents, neighbors, or siblings cannot authorize emergency treatment. This release will be in possession of your

child’s team head coach at all times.

To Whom It May Concern:

I/We hereby give permission for my/our child (print child’s name)____________________________________________

to participate in the Mt. Olive Jr. Marauders Football Association youth program. In the event of an injury, my insurance

will provide the primary coverage. Anything not paid by my insurance will be considered by the Mt. Olive Township Sports

Accident Policy, which has a $500 deductible.As the parent/guardian of the minor named above, I do hereby voluntarily

consent to rendering of treatment, by a qualified and licensed medical doctor, authorized members of the hospital staff,

or their designee, in the event of a medical emergency. Which, in the opinion of the attending physician, may endanger

their life, cause disfigurement, physical impairment, or discomfort if delayed. This includes diagnostic procedures, med-

ical/surgical/dental treatment, and/or blood transfusions. This authority is granted, only after a reasonable effort has been

made to contact myself, for the period of August 1st through November 30th, of the current calendar year.

I hereby acknowledge that no guarantees have been made to me, as to the affect of such examinations and/or treat-

ments. I have read this form and certify that I will be responsible for all reasonable charges, in connection with the care

and treatment rendered during this period.

Please specify any medical allergies, chronic illnesses, medicines regularly taken, and/or any other condition(s)

– i.e. Diabetes, A.D.D., etc.:

CHILD’S NAME: _____________________________PARENT/GUARDIAN:__________________________

ADDRESS:______________________________________________________________________________

HOME PHONE: _________________ WORK PHONE:_______________CELL/PAGER:_______________

EMERGENCY CONTACT 1: _______________________________________________________________

HOME PHONE: _________________ WORK PHONE: _______________CELL/PAGER:_______________

EMERGENCY CONTACT 2:________________________________________________________________

HOME PHONE: _________________WORK PHONE: _______________CELL/PAGER: _______________

PHYSICIAN: ___________________________________________ PHONE: _________________________

INSURANCE: POLICY #: __________________________________________________________________

Signature of Parent and/or Guardian: ____________________________________Date: _____________

Mt. Olive Jr. Marauders Football Medical Release Form