Child Medical Release Form
|
Name:
________________________________
Date of Birth:
____/____/____
Date of Last Tetanus Shot:
____/____/____
Allergies:
________________________________
Other Medical Conditions:
________________________________
________________________________
________________________________
________________________________
Primary Physician:
________________________________
Primary Physician's Phone Number:
________________________________
Name of Parent / Guardian:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Home Phone:
________________________________
Cell Phone:
________________________________
Emergency Contact:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Home Phone:
________________________________
Cell Phone:
________________________________
Medical Insurance:
________________________________
Phone Number:
________________________________
Policy Holder:
________________________________
Policy Number:
________________________________
As the parent / legal guardian of the above mentioned child. I hereby request that in my absence the above named child will be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists and or medical staff that are duly licensed as Doctors of Medicine or Doctors of Dentistry or other licensed technicians or nurses to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above mentioned minor. I understand that I have not been given a guarantee at to the results of the medical examination or treatment. I hereby authorize the hospital or medical facility to dispose of any specimen or tissue that is taken from the above listed player.
________________________________
Signature of Parent / Guardian
Sworn to and subscribed before me on
the _____ day of _______, Yr ____
Notary Public
________________________________
Commission Expires:
____/____/______
|
|
|
