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):______________________
(Work):________________________________  (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:___________________________________________________________
Physician's phone number:______________________________________________________ 
Known allergies of child:________________________________________________________
___________________________________________________________________________

Signature (parent):_____________________________________________________________
Parent's name (print):___________________________________________________________
Date:________________________