MEDICAL RELEASE FORM

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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