MEDICAL RELEASE FORM

I, _____________________________ (Parent/Guardian's Name) hereby give permission for any and 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: __________________________

INSURANCE COMPANY: _______________________________________________________

POLICY NUMBER: _______________________________________________________

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

* COACH: ______________________________________________________________

* ASST. COACH: ______________________________________________________________

* MANAGER: ______________________________________________________________

* A league representative where my child is playing.

* Any tournament representative where my child is participating in a tournament.

PHYSICIAN: __________________________________________________________________

ADDRESS: __________________________________________________________________

__________________________________________________________________

PHONE: __________________________

CONSENT FOR MEDICAL TREATMENT (MINOR)

As the parent or legal guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.

SIGNATURE (parent/guardian) ____________________________________ DATE ______________