TSYSA MEDICAL RELEASE FORM
 

I, _____________________________________ (Parent/Guardian’s Name) herby give permission for any all medical attention to be administered to my child,_______________________________ (Child's Name) in the event of accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below.

ADDRESS: ________________________________________________________________________

HOME PHONE: __________________________ WORK PHONE: __________________________

INSURANCE CO: __________________________________________________________________

POLICY NUMBER: ______________________________________________________________

In case I cannot be reached, any of the following persons are designated to act on my behalf.

COACH: _______________________________________________________________

ASST. COACH:_________________________________________________________

MANAGER: ____________________________________________________________

* or a league representative where my child is playing or participating in a tournament.

PHYSICIAN: ______________________________ PHONE #______________

ADDRESS: ________________________________________________________________________

MEDICAL CONDITIONS: __________________________________________________________

KNOWN ALLERGIES: _____________________________________________________________

SIGNATURE ____________________________________________ DATE ____________________
                                 (PARENT/GUARDIAN)

Subscribed and sworn before me, this _________ day of ___________________, 200______

____________________________________________
Notary Public

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