MEDICAL RELEASE FORM

This form will get printed and will be provided to your Child’s Manager to keep on file.

A copy will be stored in the Snack Shacks at Horseshoe Trails and Fitz Field in case of emergency!

Start by Selecting Sport & Division

This must be completed for EVERY Player Enrolled

Sport *

PLAYER / GUARDIAN INFO

Player Name *

First

Last

Date of Birth *

Gender *

Parent / Guardian Name *

First

Last

Relationship *

Parent / Guardian Name (2)

First

Last

Relationship (2)

Player Address *

Address Line 1

Address Line 2

City

State

Zip Code

Mobile Phone *

Home Phone

Work Phone

Email *

PLAYER / 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 *

Physician Phone *

Physician Address *

Address Line 1

Address Line 2

City

State

Zip Code

Hospital Preference *

Parent Insurance Co *

Policy Number *

Group ID # *

Emergency Contacts, If parent(s)/legal guardian cannot be reached

Emergency Contact *

First

Last

Phone *

Relationship to Player *

Emergency Contact (2) *

First

Last

Phone (2) *

Relationship to Player (2) *

Number of allergies/medical problems *

Number of allergies/medical problems, including those requiring maintenance medication (i.e. Diabetic, Asthma, Seizure Disorder)