Medical Release

I hereby give my permission for any and all medical attention necessary to be administered to my child,______________________

In the event of an accident, injury, sickness, etc. under the direction of the

person(s) listed below, until such time as I may be contacted. This release

is effective for a period of one year from the date given below. I also hereby assume the responsibility for payment of any such treatment.

My address is ________________________________________

________________________________________

Phone Numbers: Home_______________Work_____________

My insurance company is:_______________________________

through ___________________________________

My policy number is ___________________________________

In case I can not be reached, either of the following is designated:

Coach:________________________________ _____________

(name, area code, telephone number(s)

Team Manager:______________________________________

(name, area code, telephone number(s)

Our physician is:______________________________________

_______________________________________

(area code, telephone number)

(Parent)

Date:___________________________