Medical release As the parent/legal guardian of: , I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists and staff, duly licensed as Doctors of Medicine, Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above named player. Date of Players birth (Mo./Day/Y):Date of last Tetanus Booster: Known Allergies of this player, including any allergies to medicine Any other known medical problems: Family Physician: Phone: Name of Parent/Guardian: Cell Phone: Address: City: State: ZIP: Home Phone: Work Phone: Person Responsible for Charges (if different from above): Cell Phone #: Address: City: State: ZIP: Home Phone: Work Phone: Person to Notify if Parent/Guardian Unavailable: Cell Phone: Home Phone: Work Phone: Insurance Carrier: Policy Number: Code:
