Medical Release Form for Student Athletes

Download this Form

Participant Information

Athlete’s Name

Date of Birth

Age

Sport

Parent / Guardian Name

E-mail

Parent/Guardian Telephone

Address

City

State

Zip

Emergency Contact

Name

Relationship to Athlete:

Emergency E-mail

Telephone

Medical Information

Physician’s Name

Physician’s Phone

Insurance Provider

Policy/Group #

Allergies:

Medications

Medical Conditions

Authorization for Medical Treatment

In the event of an emergency where I cannot be reached, I hereby authorize Monarchs Inner City Youth staff, volunteers, or medical professionals to obtain or provide emergency medical treatment for my child as deemed necessary. I understand that every effort will be made to contact me prior to such treatment and that I am responsible for all related medical expenses.

Parent/Guardian Signature

Date

Player Signature:

Date