EMERGENCY
MEDICAL TREATMENT RELEASE FORM
In the event my child, named below, is injured during a practice, scrimmage, league or tournament game, or other authorized team activity, at which I am not present, and if medical attention is required, I hereby authorize the team coach, an assistant coach or the team manager to sign any necessary medical release forms on my behalf.
Player’s Name:
_________________________________________________________
Family Doctor or
Clinic: ___________________________________________________
Address:
_________________________________________________________
Telephone
Number: ________________________________________________
Address:
_________________________________________________________
Telephone
Number: ________________________________________________
Hospitalization
Insurance Company Name: ___________________________________
Policy
Number: ____________________________________________________
SPECIAL MEDICAL INFORMATION: Does your child have a medical condition that may require special attention? (Example: Asthma, Diabetes, etc.)
Yes ( ) No ( )
If yes, please describe.
________________________________________________________________
________________________________________________________________
Does your child have an allergic reaction to any medication?
Yes ( ) No ( )
If yes, please indicate the name of the medication(s).
________________________________________________________________
________________________________________________________________
Parents/Guardians Signature:_____________________________Date: ____________
_____________________________Date: ____________