Medical Release Form

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1/9 EXAMPLES

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:
PHONE:
KNOWN ALLERGIES:
SIGNATURE
(PARENT/GUARDIAN)
Subscribed and sworn before me
day of
, 20
Notary Public
Medical Release Form