Please print, complete, and return this form to your coach.
(Your coach must show a medical release form for each player at registration.)

I hereby give permission for any and all medical attention necessary to be administered to my child (name) ________________________ in the event of accident, injury, sickness, etc., under the direction of either of the person(s) designated below, until such time as I may be contacted. If neither of the person(s) designated below can be contacted, I give permission for treatment of my child as may be required subsequent to a determination made by the appropriate health care professional who is present.  This release is effective until revoked, in writing, by me. I also hereby assume responsibility for payment of such treatment.

My name:______________________________Phone (Home):_______________________

Phone (Work):__________________________Phone (Cell):_________________________

My address:________________________________________________________________

City:___________________________________________ State:_________ Zip:__________

My insurance company is:______________________________________________________

My insurance policy number is:__________________________________________________

In case I cannot be reached, either of the following is designated:

Coach:__________________________________ Phone:___________________________

Assistant coach:___________________________ Phone:___________________________

My physician:_____________________________ Phone:___________________________

Physician's address:__________________________________________________________

Known allergies of child:______________________________________________________

__________________________________________________________________________

Signature (parent):___________________________________________________________

Parent's name (print):________________________________________________________

Date:________________________