Aau Medical Release Form
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1AAU MEDICAL RELEASE FORM
As the parent/legal guardian of
, 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 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.
Date of Player’s Birth ____/_____/_____
Date of last Tetanus Booster ____/_____/_____
Month Day
Year
Month
Day
Year
Known allergies of this player, including any allergies to medicine
Any other medical problems which should be noted
Family Physician / Phone
______________________________________________________________________
Name of Parent/Guardian
Address ________________________________________________________________________
City/State/Zip
Phone H
W
F
Person responsible for charges
(if different from above)
Address________________________________________________________________________
City/State/Zip
Phone H
W
F
Person to notify if parent/guardian is unavailable
Phone H
W
F
Insurance Carrier / Policy Number
Signature of Parent/Guardian
[NOTARIZATION]
STATE OF
COUNTY OF
Sworn to and subscribed before me on the
day of ,
, 20
Notary Public in and for the State of _____________________________________
My Commission expires __________________________________________
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Parent category: Legal