MEDICAL RELEASE FORM
I,_____________________________ (Parent/Guardian's Name) hereby give permission for
any and all medical attention to be administered to my child ____________________________
(Child's Name) In the event of accident, injury, sickness, etc., under the direction of
the person(s) listed below, until such time as I may be contacted.
I also assume the
responsibility for the payment of any such treatment. This release is effective for
the period of one year from the date given below.
ADDRESS:
______________________________________________________________________
.
______________________________________________________________________
HOME PHONE:
______________________________________________________________________
INSURANCE COMP:
______________________________________________________________________
POLICY NUMBER:
______________________________________________________________________
In case I cannot be reached, any of the following persons is designated to act on
my behalf.
* COACH:
___________________________________________________
* ASST.COACH:___________________________________________________
* MANAGER:
___________________________________________________
* A league representative where my child is playing.
* Any tournament representative where my child is participating in a tournament
PHYSICIAN: ____________________________________________________________
ADDRESS: _____________________________________________________________
PHONE: _______________________________________________________________
KNOWN ALLERGIES:____________________________________________________
SIGNATURE (PARENT/GUARDIAN) ________________________DATE
__________________
Subscribed and sworn before me,
this ______ day of __________________ , 200_
________________________________________________
Notary Public