Medical Consent / Release Form printable pdf download

Medical Consent / Release Form

MEDICAL CONSENT / RELEASE FORM

Appointment of Health Care Representative

As the parent/legal guardian of

, I request that in my absence the

above named CHILD/PLAYER/ or ADULT be treated by and admitted to any hospital or medical

facility for diagnosis and treatment. I request and authorize physicians, nurses, dentists and other medical

staff, to perform any diagnostic, treatment, and/or operative health care procedures that are medically

necessary to the above named individual.

I hereby accept financial responsibility for any and all medically necessary treatment administered to the

above named CHILD/PLAYER/ or ADULT in the event of an accident, injury, sickness, etc. to the same extent

as if I had personally contracted for such care and services and agree to pay all such charges.

Any representative of the following organization is designated to act on my behalf as my personal

representative during my unavailability or inability to act:

The following individual(s) is designated to act on my behalf as my personal representative during my

unavailability or inability to act:

These powers shall be effectively immediately and shall not terminate unless revoked by me in writing with

notice to all interested parties.

General Release

I understand the above named CHILD/PLAYER/ or ADULT assumes all of the risks associated with the

activities in which he or she will be involved. I release all rights and claims for damages which the above

named CHILD/PLAYER/ or ADULT, their heirs, executors, and administrators, or I may have against

, its directors, coaches, officials, teachers or

representatives for injuries or damages that occur as a result of their participation.

Date of birth ___/___/___ for the above named individual.

Date of last Tetanus Booster ___/___/___ for the above named individual.

The following is a list of known allergies and allergies to medications of the above named individual:

The above named individual has the following known medical conditions or problems:

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Medical Consent / Release Form