Medical Release Form printable pdf download

MEDICAL RELEASE FORM

I hereby give my permission for any necessary emergency medical attention to be administered

to my child, _____________________________ in the event of any accident, injury, sickness,

etc. under the direction of the person(s) listed below, until such time as I may be contacted. This

release is effective for the normal season (up to one year) from the date given below. I also

hereby assume the responsibility for payment of any such treatment.

My address is: _________________________________________________________________

_________________________________________________________________

My Phone number(s) are: Home__________________ Work__________________

My Medical Insurance Company is: _____________________________________

My Policy number is: ________________________________________________

In case I cannot be reached, either of the following is designated to act on my behalf:

Coach: _______________________________________________________________________

Asst. Coach: __________________________________________________________________

Our Physician is: ______________________________________________________________

Physicians Address: ____________________________________________________________

Physicians Phone Number: _______________________________________________________

Known Allergies, and/or other medical notes:_________________________________________

_____________________________________________________________________________

Parent or Legal Guardian Signature: ________________________________________________

Subscribed and sworn to before me this_________day of _____________, 20__

_______________________________

Notary Public

Medical Release Form