Homer Youth League

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Medical Release Form

* Player's Name:

* Date of Birth:

* Gender:

* Parent(s)/Guardian Name:

* Relationship:

* Parent/Guardian Phone:

Parent(s)/Guardian Name:

Relationship:

Parent(s)/Guardian Phone:

* Player's Address:

* City:

* State:

* Zip Code:

PARENT OR GUARDIAN AUTHORIZATION: In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, ER Physician) *

* Family Physician:

* Phone:

* Address:

* City:

* State:

* Hospital Preference:

* Parent Insurance:

If parent(s)/guardians cannot be reached in case of emergency, contact:

* Name:

* Phone:

* Relationship to player:

* Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. asthma, diabetic, seizure disorder):

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Checking this box serves as the authorized parent/guardian signature *

* indicates required fields

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Medical Release Form