Medical Release Form
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Player Name *
DOB *
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Medical Insurance Carrier *
Carrier Phone Number *
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, E.R. Physician)
Family Physician
Phone
Address *
Hospital Preference *
In case of emergency contact:
Name of Primary Emergency Contact *
Phone *
Relationship to player *
Name of Secondary Emergency Contact *
Phone *
Relationship to player *
Allergies/Medical History
Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder). Please notate "none" if not applicable. *
Date of last Tetanus Toxoid Booster
Waiver
WARNING: Protective equipment cannot prevent all injuries a player might receive while participating in sports. TB Sports LLC, USA Patriots, Inc., USA Baseball Softball Academy, LLC & M3PAT, LLC, all officers, directors, organizers, sponsors & person transporting my/our child to and from activities does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference or religious preference. *
Required
Name of person completing this form *
Relationship to Player *
Form Completion Date *
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Submit
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