Player Medical Information & Liability Release
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1
2Player Medical Information &
Liability Release
Player’s Last name
First Name
MI
Gender
Home Street Address
Home City
Home State
Birthdate
Father’s Name
Father’s Cell
Mothers Name
Mother’s Cell
TO BE COMPLETED ONLY IF CHILD IS LEFT WITHOUT PARENT OR GUARDIAN
In an emergency, when a parent cannot be contacted, the following people should be notified
Person 1: _____________________________________________
Phone: _______________________
Person 2:______________________________________________
Phone: _______________________
Physician’s name
Physician’s Phone
Hospital/Medical Insurance Company
Policy Holder’s Name
Policy Number
Hospital/Medical Insurance Phone
List any allergies the player has. (Enter “None” if none)
List any medical conditions or prohibitions the player has. (Enter “None” if none)
THE LIABILITY RELEASE ON THE BACK SIDE OF THE FORM MUST BE COMPLETED IN ALL CIRCUMSTANCES
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Parent category: Legal