Montrose Avalanche Medical Release Form

Please fill out and submit this form to the Montrose Avalanche Registrar.

As the parent/legal guardian of*
I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and a uthorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.*
- I agree
- I do not agree
Player Information
Player's Date of Birth*
Player's Last Tetanus Shot
Known allergies of this player, including any allergies to medicine*
Family Physician*
Phone
Parent/Guardian Information
Name of Parent/Guardian*
Address*
Street AddressAddress Line 2CityStateZip Code
Phone*
Work Phone
Fax
Person Responsible for Charges (if different from above)
Address
Street AddressAddress Line 2CityStateZip Code
Phone
Work Phone
Fax
Emergency Contact
Person to Notify if parent/guardian is unavailable*
Phone*
Work Phone
Fax
Insurance Informaton
Insurance Carrier
Policy Number
Signature
Signature of Parent/Guardian (Type your Name)*
Please type your name
By checking this box, I acknowledge my digital signature on the Montrose Avalanche Medical Release Form*
- Signature of Parent/Guardian
Email*
Please type the words below.
Name
This field is for validation purposes and should be left unchanged.

Montrose Avalanche Medical Release Form

Player Information

Parent/Guardian Information

Emergency Contact

Insurance Informaton

Signature

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