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My Health Record - rcbrochesterny.com

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					ROC CITY BALLERS BASKETBALL CLUB MEDICAL RELEASE FORM
I hereby give 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 Roc City Ballers coaching staff until such time as I may be contacted.
My child's name is ______________________________________.
This release is effective for the time during which my child is participating in the
    Spring AAU Basketball Season; this includes practices and any tournaments
they will compete in for the       season, including traveling to and from such
tournaments. I hereby assume responsibility for payment of any such treatment.

Parent or Guardian Name (Please print in all caps)______________________________________________________________

Parent Address (Street, City, State and Zip) _____________________________________________________________________

Home Phone____________________________             Work/Daytime Phone_____________________

Cell Phone______________________________            Other Phone ____________________________

Emergency Contact ______________________________ Emergency Contact Phone #_____________________________

Medical Insurance Company   _______________________________________________      Medical Insurance Policy #   _______________________________________________

_________________________________     __________________________________________
Family Physician                        Phone Number (area code) XXX-XXXX

_______________________________     ______________________________________      _________________________
Physician’s Address                            City                                 Zip


Parent or Guardian Signature _____________________________________________________             Date ________________
                                                                Health Record
                       Name                                                                 Emergency Contact Name
                   Birth Date                                                                               Address
            Medical Plan/ID #                                                                                Phone
Pediatrician's Name & Number                                                                        Alternate Phone




                Immunization History          Known Medical Conditions/Allergies                     Medications
         Date                          Type       Name                 Description   Name     Description             Dosage




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posted:3/9/2011
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