Fox Lane Youth Football - (Mount Kisco, NY) - powered by LeagueLineup.com

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Medical Release Form

PLAYER INFORMATION

* Last Name:

* First Name:

* Street:

* City:

* State:

* Zip Code:

PARENT/GUARDIAN #1

* First name:

* Last name:

* Cell Phone:

PARENT/GUARDIAN #2

* First name:

* Last name:

* Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

Relationship to Player:

* Child's Doctor & Phone #:

* Insurance Carrier:

* Policy #:

* Any allergies or medical problems?:

Medicines child is taking (if any):

WAIVER INFORMATION

I authorize an adult of the Fox Lane Youth Football who resides in the State of New York to consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the above named minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the Continental United States, when the need for such treatment is immediate, and when efforts to contact me (us) are unsuccessful.

I/we agree with the above *

* indicates required fields