Madness Medical Release Form 2019-2020

Address *

Home Phone

Area Code Phone Number
Mom's Cell

Area Code Phone Number
Dad's Cell

Area Code Phone Number
E-mail *
E-mail 2
example@example.com
EMERGENCY INFORMATION:
In case I cannot be reached, any of the following people are designated to act for me:
Coaches' Names
If parents cannot be immediately contacted in case of emergency, contact:
Emergency Contact Name

First Name Last Name
Relationship
Emergency Contact's Phone Number

Area Code Phone Number
MEDICAL INFORMATION
Physician Name

First Name Last Name
Phone Number

Area Code Phone Number
Insurance Name *
Group/Policy Number
Policy Information *
Group/Policy Number
Allergies
Medical Concerns
CONCENT:
I hereby give permission for any and all medical attention necessary to be administered to my child, (player's name listed above), in the event of an accident, injury, sickness, etc. under the direction of the people listed above until such time as I may be contacted.

This release is effective for the time during which my child is participating in league play and for all practices and tournaments which her team is participating in during the 2019-2020 season, including traveling to or from practices, league and tournament games. I also hereby assume the responsibility for payment of any such treatments.
Should be Empty:

Madness Medical Release Form