Medical Information & Release

NOTE: This form is to be carried by Team Coach together with team roster at practices, games and/or tournaments.

Player Name:_________________________ Date of Birth:_____________ Parent or Guardian Authorization:

In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R. Physician)

Family Physician:____________________________Phone:__________________ Address:_____________________________City/State________________ Hospital Preference:__________________________________________________ Please list any allergies or medical problems, including any current maintenance medications (i.e. Diabetes, Asthma, Seizure disorder)
Diagnosis Medication Dosage How often?

Date of last Tetanus Booster:______________________________________________

The purpose of gathering this information is to make sure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Authorized Parent or Guardian Signature

Date