3d0a367e-a6a6-471c-a0b9-81d5ae89a219.doc, Created on 1/2/2007 5:33:00 PM
MEDICAL RELEASE FORM* – Date Effective ___________________________________________ In case of emergency, I understand every effort will be made to contact me. In the event I cannot be reached, I hereby give my permission to obtain any emergency medical, dental, or surgical treatment for my child, which may include hospitalization, anesthesia, surgery, or injections of I understand that I am responsible for any bills thus incurred.
(print child's name- first, last)
Child’s DOB
date
(print parent/guardian name)
(signature – parent/guardian)
Physician’s name and phone
Physician’s Address
Health Insurance Provider
ID#
Group #
Please list any allergies to:
Any other conditions or allergies we should be aware of?
Does the student wear contact lenses?
Please list any medications the student takes regularly?
Home Phone
Work
Mother’s Cell Phone
Father’s Cell Phone
Name, relationship & phone of emergency contact if parents are unavailable _____________________________________________________________________________________ *This generic form is in no way an official form of the NCFCA, Region IX, or the tournament registrar. It is solely for your convenience. Updated 11/07