Medical Release Form (REQUIRED TO PLAY)

Insturctions for Medical Release Form
1) Copy and Paste below onto a word document
2) Have Parents fill Out
3) Turn it into your captain ASAP so he can get the roster in
4) Remember if you NO Medical Release NO PLAY!


COPY from HERE ON DOWN

HSM Saddleback Church
Medical Release and Registration Form

I give my Student permission to take part in
Killball “Dodgeball Tournament” - April 26th, 2008

In the event that he or she is injured while participating, I do hereby authorize and consent to any x-ray, examination, anesthetic, medical, or surgical diagnosis rendered under general or special supervision of any licensed medical staff member under the provisions of the Medicine Practice Act. It is understood that this authorization is given in advance of any specific diagnosis or treatment being required, but is given to provide authority and power to render care which the aforementioned physician, in his or her best judgment, may deem advisable. It is understood that effort shall be made to contact me, the undersigned, prior to rendering treatment to my child, but that any of the above treatment will not be withheld if I cannot be reached. This authorization is given pursuant to the provisions of section 25.8 of the Civil Code of California. I understand the nature of this event and do hereby release Saddleback Valley Community Church, or any of its representatives, from any liability for accidents or injury sustained by my child in conjunction with this event.

Signed _________________________________________________________

Date____________________________


STUDENT INFORMATION

TEAM NAME: ___________________________________________________

Student’s Full Name ______________________________________________


Student’s email __________________________________________________


Phone_________________________________________________________

Age _____

Birth Date ____ / ____ / 19___ Sex: M / F

School _________________________________________________________

Grade __________________

Street Address ___________________________________________________

City, State, Zip ___________________________________________________

IN CASE OF EMERGENCY, NOTIFY:

Full Name ______________________________________________________

Relationship to student _____________________________________________

Phone #1 _______________________________________________________

Phone #2 _______________________________________________________

MEDICAL INFORMATION

• Does your child have any special physical or mental problems of which we should be aware? If so, please describe on the back of this paper.

• Does your child take any medications on a regular basis? If so, please list them on the back of this paper, and be sure to include the amounts.

Family Doctor____________________________________________________

Phone ________________________________________________________