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 __________________