St. Maria Goretti School

 

2011-12 Athletics Medical Release Form

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This form is required before any participation can begin.

 

This gives permission to a licensed Medical Physician to administer treatment to the following minor in the event of a medical emergency that which in the opinion of the attending physician may endanger 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.

Please fill in the information below and submit this form. (* indicates required field.)

 

*Student Athlete Name:
Date of Release: August 2011 TO May 2012 athletic season The release is signed of my own free will for the sole purpose of authorizing medical treatment under emergency circumstances in my absence.
*Parent/Guardian Name:	Typing your name in this box indicates your electronic signature.
Relationship to Student:	Father Mother Guardian
*Address:
*City/State/Zip:
*Phone:
*Email:

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*Hospital:
*Family Physician:	*Physician Phone:
Specified Medical Allergies:
Chronic Illness:
Other Condition:

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Other Contact Information In Case of Emergency:
*Name:	*Phone:

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*Hospital Insurance:	*Group Number:
*Surgical-Medical:	*Group Number: