Greater Binghamton United Medical Release Form
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1Greater Binghamton United FC
Medical Release Form
As the parent/legal guardian of _____________________________________, I
request that in my absence the above-named minor 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 diagnostic procedures,
treatment procedures, operative procedures, and x-ray treatment of the above-
named minor.
I have not been given a guarantee as to the results of the
examination or treatment. I authorize the hospital or medical facility to dispose of
any specimen or tissue taken from the above-named minor.
Date of Player’s Birth: ___/___/___
Date of last Tetanus Booster: ___/___/___
Known allergies of this player, including allergies to medicine:
______________________________________________________________________
Please identify any other medical issues that should be noted:
Family Physician: ___________________Contact Phone #: (
) ______ _________
Name of Parent/Legal Guardian: _________________________________________
Address: ____________________________________________________________
City: ____________________________ State: _________
Zip: _____________
Home Phone #: (
) _____- ______
Work Phone #: (
) ______ - _________
Cell Phone #:
(
) ______ - _________
Insurance Carrier: _______________________________________
Policy Number: _________________________________________
Hospitalization Insurance: YES
NO (Please circle one)
Signature of Parent/Legal Guardian:
______________________________________
Printed Name of Parent/Legal Guardian:
______________________________________
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Parent category: Legal