MEDICAL RELEASE FORM

As the parent/legal guardian of _______________________, 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. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the abovenamed player.

Date of Players Birth _____/_____/_____ Date of last Tetanus Booster _____/_____/_____

Known allergies of this player, including any allergies to medicine

___________________________________________________________________________________

Any other medical problems which should be noted __________________________________________

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Family Physician ____________________________ Phone ( )_________-____________________

Name of Parent/Guardian ______________________________________________________________

Address ____________________________________________________________________________

City/State/Zip ________________________________________________________________________

Phone ___________________H _______________________W ____________________________FAX

Person responsible for charges (if different from above) _______________________________________

Address ____________________________________________________________________________

City/State/Zip ________________________________________________________________________

Phone ______________________H _________________________W _______________________FAX

Person to notify if parent/guardian is unavailable _____________________________________________

Phone ______________________H _________________________W _______________________FAX

Insurance Carrier _______________________________ Policy Number __________________________

Signature of Parent/Guardian ____________________________________________________________