Medical Authorization Form printable pdf download

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:

Medical Authorization Form