Medical Release Form

 

As the parent/legal guardian of ___________________________________, I request that in my absence the above-named player be admitted to any hospital facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment 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. This information will remain confidential.

Date of Players Birth ___/___/___ Date of last Tetanus Booster ___/___/___

Known allergies of this player, including any allergies to medicine _______________________________

 ____________________________________________________________________________________.

Any other medical problems that should be noted_____________________________________________

 ____________________________________________________________________________________

Family Physician ______________________________________Phone (      )______________________

Name of Parent/Guardian ________________________________________________________________

Address ______________________________________City/State/Zip ____________________________

Phone (      )_____________________H (      )____________________W (      )__________________Fax

Person responsible for charges (if different from above) _______________________________________

Address ______________________________________City/State/Zip ____________________________

Phone (      )_____________________H (      )____________________W (      )__________________Fax

Person to notify if Parent/Guardian is unavailable ____________________________________________

Phone (      )_____________________H (      )____________________W (      )__________________Fax

Insurance carrier _____________________________ Policy Number _______________

 

Waiver of Liability

 

By signing below, I ______________________________________(please print name) do hereby indicate that the above information is accurate and give my permission for ________________________________________ (please print child’s name) to play in the Kokomo Soccer Club program.  I will not hold the Kokomo Soccer Club or its representatives responsible for any accidents or injuries that may occur during Club sponsored events or activities.

 

Signed:   ________________________________________________________  Date: ________________________