AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS Name of minor Age

AUTHORIZATION FOR MEDICAL TREATMENT OF MINORS Name of minor Age Grade Sex DOB Address________________________________City_________________Zip Code________________ Father/Guardian_____________________________Mother/Guardian__________________________ Address____________________________________Address_________________________________ If not the same If not the same City/Zip_____________________________________City/Zip_________________________________ Cell#________________Bus. #________________ Cell#________________Bus. #________________ Home#_______________Other#_______________ Home#_______________Other#_______________ Emergency Contact Person_________________________Relationship________________________ Home#_________________Cell#________________Bus#_______________Other________________ Medical Ins_______________________________Policy/Group #______________________________ Identify allergies or special conditions I/We, being the parent(s) or legal guardian(s) of the above named minor, do hereby appoint: Aloha Youth Lacrosse Association, Inc., 3075 Pacific Heights Road, Honolulu, HI 96813 to act in my/our behalf in authorizing unexpected medical, surgical care and hospitalization for the above named minor during the period of my/our absence, from: Sept. 2007 through Dec. 31, 2008 Physician: Phone Dentist: Phone ____________ Parent/Guardian Signature_____________________________________________________________