ST. ROSE OF
EMERGENCY TREATMENT FORM
Fill out, print out, sign and return to the Head Coach
As
a parent and/or guardian of, a minor, I herewith authorize treatment by a
qualified and licensed medical doctor in the event of a medical emergency
which, in the opinion of the attending physician, may endanger his or her life,
cause disfigurement, physical impairment, or undue discomfort if delayed. This
authority is granted only after a reasonable effort has been made to reach me.
NAME OF PARENT OR GUARDIAN
ADDRESS
PHONE
FAMILY
PHYSICIAN PHONE
DATES
DURING WHICH RELEASE IS GRANTED:
FROM TO
SPECIFIC
MEDICAL ALLERGIES, CHRONIC ILLNESS OR OTHER MEDICAL CONDITIONS STAFF SHOULD BE
AWARE OF:
OTHER
CONTACT IN CASE OF AN EMERGENCY
NAME
PHONE RELATIONSHIP
This
release form is completed and signed of my own free will with the sole purpose
of authorizing medical treatment under emergency circumstances in my absence.
____________________________
(Father,
Mother, Legal Guardian) Date