Medical Release Form

I, ______________________________, (printed Parent/Guardian’s name)

hereby give permission for any and all medical attention to be administered to my

child ______________________________ (printed Child’s Name) in the event of

an accident, injury, sickness, etc. 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

September 1, 2011 - September 1, 2012:

______________________________________________________________________

Insurance Company: ________________________________________________

Policy Number: _____________________________________________________

Group Number: _____________________________________________________

In case I cannot be reached, any of the following person(s) is/are designated to act on my behalf:

Coach:

Physician: ___________________________________________________________

Address: ___________________________________________________________

Phone: ___________________________________________________________

Known Allergies: _____________________________________________________

Current Medications and Dose:_____________________________________________

Signature (Parent/Guardian) ___________________________________________

Date: ________________________________________________________________