MEDICAL RELEASE FORM
Name of Player ______________________________Date
of Player’s Birth _________________________
I request that in my absence
the above named player be admitted to any hospital or medical facility for
diagnosis and treatment. I request and
authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine
or Doctors of Dentistry or other such licensed technicians or nurses, to
perform any diagnostic, procedures, treatment procedures, operative procedures
and x-ray treatment of the above minor.
I have not been given a guarantee as to the results of examination or
treatment.
Known allergies of this player, including any allergies to medications:
____________________________________________________________________________________
Any other medical conditions of note, i.e. special medications, inhaler:
____________________________________________________________________________________
Family Physician: ____________________________________Physician Phone:
(_____) ______________
Name of Insured: __________________________________________
Insurance Co.: ______________________________________Policy
#: ___________________________
Insurance Phone #: (_____)
________________________
Person responsible for charges: _________________________________________
Street Address: ______________________________________City:
______________________________
State: ________________ Zip: _________________
Phone #: Home (_____) _____________________ Work or Cell #: (_____) _______________________
Alternate emergency contact::
Name:________________________________ Phone #: _________________
Fill out the following if the
Parent/Guardian is different than the “Person responsible for charges” listed
above.
Parent/Guardian: _____________________________________________________
Street Address:
State: _________________ Zip: _________________
Phone # Home: (_____) ______________________ Work or Cell #: (_____)
_______________________
Signature of Parent/Guardian: _________________________________________________________
Date: ___________________________
(The Coach shall maintain
this information in confidence. The
forms will be returned at the end of the season, if requested)