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Medical Release Form Example
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Text in this example:
I, hereby give permission for any and all medical attention to be (Parent/Guardian's Name) administered to my child in the event of accident, injury, sickness, etc. (Child's Name) 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: INSURANCE COMPANY: 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) Subscribed and sworn before me day of , 20 . Notary Public Medical Release Form