Mass City Medical Release Waiver
As the parent/guardian, I request that in my absence, the player named be admitted to any hospital or care facility for diagnosis and treatment. I request and authorize physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures, and x-ray treatment to the named minor. I have not been given any guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue of the named player.
Email *
Parent/Guardian Name *
Player Name *
Player's Date of Birth *
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DD
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Date of Tetanus Booster *
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DD
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YYYY
Known Allergies *
Other Medical Problems *
Address *
Contact Number *
Second Emergency Contact Name *
Second Emergency Contact Number *
Insurance Carrier *
Group/Policy Number *
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