MEDICAL RELEASE FORM 

I, ________________________________________, Parent/Guardian's Name) hereby give permission for any and all medical attention to be administered to my child,

___________________________________________ (Child's Name) in the event of 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 one year from the date given below.

ADDRESS:           

_________________________________________________________________________________________

_________________________________________________________________________________________

                          HOME PHONE:        

_________________________________________________________________________________________

INSURANCE COMP:    

_________________________________________________________________________________________

In case I cannot be reached, any of the following persons is designated to act on my behalf. 

*  COACH:       ___________________________________________________

*  ASST.COACH:  ___________________________________________________

*  MANAGER:     ___________________________________________________ 

*  A representative of the league where my child is playing.

*  Any tournament representative where my child is participating.

PHYSICIAN: ___________________________________________________________

ADDRESS: _____________________________________________________________

PHONE: _______________________________________________________________

KNOWN ALLERGIES: _____________________________________________________

SIGNATURE (PARENT/GUARDIAN) ____________________________________ DATE __________________

Subscribed and sworn before me, this ______ day of __________________, 20______