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