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    SeattleRowing
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    This medical release form gives permission for medical treatment to be administered to a child in the event of an accident or injury for a period of one year. It provides the parent or guardian's contact information, insurance details, and designates coaches, assistant coaches, or event representatives to act on their behalf if they cannot be reached. The form also lists the child's physician, any known allergies or health conditions, and requires the signature of the parent or guardian and date.

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    SRC Medical Form

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    This medical release form gives permission for medical treatment to be administered to a child in the event of an accident or injury for a period of one year. It provides the parent or guardian's contact information, insurance details, and designates coaches, assistant coaches, or event representatives to act on their behalf if they cannot be reached. The form also lists the child's physician, any known allergies or health conditions, and requires the signature of the parent or guardian and date.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    58 views1 page

    Medical Form

    Uploaded by

    SeattleRowing
    This medical release form gives permission for medical treatment to be administered to a child in the event of an accident or injury for a period of one year. It provides the parent or guardian's contact information, insurance details, and designates coaches, assistant coaches, or event representatives to act on their behalf if they cannot be reached. The form also lists the child's physician, any known allergies or health conditions, and requires the signature of the parent or guardian and date.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
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    MEDICAL RELEASE FORM

    I, _______________________________(Parent, Guardian’s Name) hereby giver 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:
    ____________________________________________________________________
    ___________________________________________________________
    ______

    INSURANCE COMPANY: ____________________________________________________


    POLICY NUMBER:
    _________________________________________________
    In case I cannot be reached, any of the following persons is designated to act on my behalf:

     Coach: _______________________________________________________________

     Asst. Coach: ___________________________________________________________

     A representative where my child is racing.

    PYSICIAN:
    ____________________________________________________________________________
    ADDRESS:
    ______________________________________________________
    PHONE:
    ________________________________________________________
    KNOWN ALLERGIES:
    ______________________________________________
    HEALTH CONCERNS OR CONDITIONS:
    __________________________________
    ____________________________________________________
    _________

    SIGNATURE (PARENT/GUARDIAN): DATE:

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