FORT WORTH BATBUSTERS 18U (BOYD)

MEDICAL RELEASE FORM

Medical Release Form

And Authorization for Medical Treatment

Player’s Name _________________________________ Date of Birth: ___________________

Father’s Name: ___________________ Mother’s Name: ______________________________
Player’sAddress:________________________________________________________________
Home Phone Number(s): ___________________ Work Phone Number(s): _______________
Cell Phone Number(s): ___________________

In an emergency when parents cannot be reached, please contact:

Name: _____________________________ Home Phone: ____________ Work: ___________

Name: _____________________________ Home Phone: ____________ Work: ___________

Player Information:
Please be sure the coach is aware of allergies the player may suffer from

Allergies: ____________________________________________________________________
_____________________________________________________________________________
Asthma (Yes or No): _______ Blood Type (if known): ___________________
Date of last tetanus booster: __________ Regular Medications: ________________________
Additional Information: _________________________________________________________
______________________________________________________________________________
Medical Insurance Carrier: _______________________ Policy #: _______________________
Insurance Contact Phone #: ________________ Policy Holder Name: ____________________
Player’s Physician: _______________________ Phone #: ______________________________

CONSENT FOR MEDICAL TREATMENT

I, ______________________________, am the parent or guardian having legal custody of the

above player. I authorize all medical, surgical, diagnostic, and hospital care or procedures which
may be performed or prescribed for my child by a licensed physician or hospital, when efforts to
contact me are unsuccessful and when deemed immediately necessary or advisable by the
physician to safeguard my child’s health. I waive my right of informed consent to such
treatment.

Signature: ________________________________ Date: __________________