KNOTHOLE MEDICAL RELEASE FORM

KNOTHOLE MEDICAL RELEASE FORM

MEDICAL AUTHORIZATION

PLAYER’S NAME______________________________________________

MOTHER’S NAME_____________________________________________ E-Mail ______________________________________________

Home ( )_____________ Work ( )____________ Cell ( )____________

FATHER’S NAME______________________________________________ E-Mail ______________________________________________

Home ( )_____________ Work ( )____________ Cell ( )____________

___________________________________________________________________________________________

Street Address City State Zip

In the event of illness or injury, permission is hereby granted to the coaching staff of the

(team name)_________________________________________________________ or their designated representative(s) to administer or secure

medical assistance and/or any other action as may be deemed prudent, including, without limitation, referral to licensed medical personnel or

transfer to the appropriate hospital or medical facility.

PARENT OR GUARDIAN SIGNATURE____________________________________________

MEDICAL CERTIFICATION

I hereby certify that __________________________________ is physically able to participate with the

(team name)_________________________________________________________ baseball team for the ___________ season.

Below is a listing of allergies to medication (if none, please indicate):

___________________________________________________________________________________________________________________________________

DATE ___________________ PHYSICIAN’S NAME _________________________________________________

Physician’s Address_______________________________________________________________________________

Physician’s Phone ( )______________________

MEDICAL INSURANCE INFORMATION

Hospital Plan____________________________________________ Contract No. ____________________________

Company_______________________________________________________________________________________

City __________________________________________________ State _____________ Zip _________________

Other Pertinent Information ________________________________________________________________________

_______________________________________________________________________________________________

PARENTAL RELEASE

_________________________________________has our permission to participate in all activities, including post-season tournaments not specifically scheduled.

We acknowledge that these activities may require travel in various modes of transportation with accommodations and meals in various establishments. We

acknowledge that our son participates in all activities at his own risk. In consideration of you permitting him to participate, we hereby release the coaching staff,

any sponsors, the league and national association with which the league or the (team name)_________________________________________________________

may affiliate, and the employees, agents, heirs, affiliates, officers, successors, and assigns of each from any responsibility that you or they might have regarding the

health and physical condition of our son during his participation. On behalf of ourselves, our sort, our heirs, executors and assigns, we further release and forever

discharge all the above individuals and entities from any and every claimant, demand, right or cause of action either in law or in equity arising from our son’s

participation in all activities.

The undersigned agree to indemnify, and hold harmless all the above individuals and entities from any claim made in derogation of this release.

Date _____________ Parent or Guardian Signature _______________________________________________________

Medical Release Form April 2007