I hereby give permission for any and all medical attention necessary to be administered to my child, __________________ in the event of an accident, injury, sickness, etc. under the supervision of the person(s) listed below until such time as I may be contacted.

This release if effective for the time during which my child is participating in the _________________________ program and any tournaments for the 200___/200___ season, including traveling to or from such tournaments. I also assume responsibility for the payment of any such treatments.

Parents or Guardians Names:_______________________________________

Home Address: __________________________________________________

_______________________________________________________________

Home Phone: ___________________ Work Phone: ___________________

Insurance Company: _____________________________________________

Policy Number: _________________________________________________

Family Physician: _______________________________________________

Physician's Address: ______________________________________________

Physician's Phone: _______________________________________________

In case I cannot be reached, either of the following people is designated to authorize any necessary medical treatment.

Coach's Name: ________________________ Phone: _____________

Asst. Coach or Other: ____________________Phone: _____________

 ________________________________________________
Signature of Parent/Guardian:

Date: _____________________