Player Medical Release Form

Player Name*
First Last
Team*
Please read the statement below and place initials in the empty box.*
In the event of sickness, accident, or injury, I give permission for my daughter to have administered to her whatever emergency treatment is deemed necessary by the attending doctor/nurse/medical technician.
Medical Conditions*
My daughter has the following medical conditions or allergies, which should be noted in case of sickness, accident, or injury. (e.g., asthmatic, diabetic, allergies to specific drugs, hyper reaction to bee stings, bleeds easily, etc.). Please state “NONE” if there are no known problems or conditions.
Insurance Company Name*
(Please provide your family's insurance information)
Insurance Company Policy Number*
(Please provide your family's policy number and group number)
Parent's Name*
First Last
Parent's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Electronic Signature*
By placing your name in the box below, you are indicating that all information provided is the most accurate and up-to-date information about your child.
Today's Date*
Time*

: HH

MM

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