Medical Authorization Form


Medical Authorization Form
Player Name: ___________________________________
Current Team:__________________________________
Grant Of Consent: Part 1
In the event reasonable attempts to contact the parents or guardians have been unsuccessful,
I hereby give my consent for:
1) The administration of any treatment deemed necessary by preferred doctor/dentist or
in the event designated doctor/dentist is not available, by another licensed physician
or dentist.
2) The transfer of the child to preferred hospital or any hospital reasonably accessible.
Preferred Doctor:
Preferred Dentist:
Parent/Guardian Signature:
Phone :
Refusal of Consent: Part 2
(Do not complete if part 1 is completed)
I DO NOT give consent for emergency medical treatment of my child. In the event of illness or
injury requiring emergency treatment, I wish the Columbia Girls Fastpitch to take no action or
to perform the following actions:
Actions to be performed:
Parent/Guardian Signature:


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