Bryc Medical Release Form
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1BRYC MEDICAL RELEASE FORM
As the parent/legal guardian of
, in the
_______________________________________
event that emergency medical treatment is deemed to be necessary, 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 necessary 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.
Player's Birth Date:
___________________
List any medical problems or prohibitions (medicines being taken; allergies, including allergies
to medicine; last tetanus shot; medical history such as diabetes, heart disease, asthma, etc.):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Player’s Physician: _____________________________ Phone: ____________________________
Name of Parent/Guardian:
_______________________________________________________
_____________________________________________________________________
Address:
____________________________________________________________
City/State/Zip Code:
Phone: (Home) ___________________________
(Cell Phone) ____________________________
_____________________________________________________________
Insurance Carrier:
Policy/Group Number:
_________________________________________________________
______________________________
Person responsible for charges (if different from above):
_____________________________________________________________________
Address:
City/State/Zip Code: _
___________________________________________________________
Phone: _____________________________________________________________________________
Person to notify if parent/guardian is unavailable:
___________________________________
_
______________________________________________________________________
Phone:
Signature of Parent/Guardian
___________________________________
Date
_____________
This form is to be completed by the player’s parent/guardian and kept by the coach and must be available
at all practices and games.
Revised 07/04
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