Medical Release Form

MEDICAL RELEASE FORM

 

As the parent/legal guardian of:

 

Name of Player:______________________________________________________________

 

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 guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken directly from the above-named player.

 

Date of Players Birth:____________________________  Date of last Tetanus Booster:___________________________

 

Allergies:_______________________________________________________________________________________

 

Other Medical Conditions:__________________________________________________________________________

 

Player's Physicain:______________________________________Phone # (____)______-______________

 

 

Name(s) of Parent(s)/Guardian(s):___________________________________________________________________


Street Address:___________________________________________________________________________

City:_________________________________________ State:____________ Zip Code:_________________

 

Home Phone: (____)______-______________  Work Phone: (____)______-______________ 

 

 

Person to Notify if Parent/Guardian is unavailable:_______________________________________________

 

Street Address:___________________________________________________________________________

City:_________________________________________ State:____________ Zip Code:_________________

 

Home Phone: (____)______-______________  Work Phone: (____)______-______________

 

 

Medical Insurance Company:___________________________________ Phone: (____)______-_____________

 

Policy Holder:_________________________________    Policy Number:_____________________________

 

I hereby give my consent to the participation of the athlete listed above in the Scarborough High School Soccer Boosters Summer Soccer Program.  Parents and guardians should be aware that such activity involves the potential for injury, which is inherent in all sports.  I acknowledge that even with the best coaching, use of the most advanced equipment and strict observation of rules, injuries are still a possibility. On rare ocassions these injuries can be so severe as to result in total disability, paralysis, or even death.  I acknowledge that I/we have read and understand this warning. I shall assume all responsibility and expense for any injury received in practice or participation.  I give my permission for my son/daughter to be diagnosed and treated by a licensed physician, certified athletic trainer and those directly under their supervision should service be necessary.

 

Signature of Parent/ Guardian:____________________________________Date:_______________________