Youth Basketball Registration Form Page 2

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Eastlake Youth Basketball Medical Release Form
Parent or Guardian Authorization:
In case of an emergency, if I, or the family physician, cannot be reached, I hereby authorize my child to be
treated by a certified Emergency Personnel (i.e., EMT, First Responder, ER Physician).
Family Physician: ______________________________________ Phone (
)________________________
Address: _____________________________________________ City: _______________________________
Hospital Preference: ________________________________________________________________________
In case of an emergency, contact:
Name: ______________________________ Work Phone: __________________ Relationship to player: _______________________
Home Phone: _________________________ Cell Phone: __________________ Additional Info: _____________________________
Name: ______________________________ Work Phone: __________________ Relationship to player: _______________________
Home Phone: _________________________ Cell Phone: __________________ Additional Info: _____________________________
Please list any allergies/medical conditions, including those requiring maintenance medications:
Condition
Medication
Dosage
Frequency of dosage
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Allergies: ___________________________________________________________________________________________________
The purpose of the above information is to ensure that medical personnel have details of any medical concern which may interfere
with or alter treatment.
Date of last Tetanus Toxoid Booster: ________________________________
____________________________________________________________
________________________________________
Parent or Guardian Signature
Date

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