If Medical care is required for ________________________________ in conjunction with any activity or related transportation, and if normal permission is not available in a timely manner, the undersigned authorizes appropriate medical care as deemed necessary by emergency medical personnel, a physician, or the medical facility.

  Self,  Parent or Guardian   ____________________________________________________

ADDRESS_______________________________________________________________

__________________________________________________________________________

PHONE NUMBER ____________________ CELL_________________________________

EMERGENCY CONTACT 2ND CHOICE_______________________________________

FAMILY PHYSICIAN _______________________________________________________

ANY MEDICATION /ALLERGIES (please state)__________________________________

BIRTH DATE_____________MEDICAL INSURANCE COMPANY__________________

POLICY NUMBER__________________________________________________________

SPECIAL INSTRUCTIONS FOR MEDICAL ____________________________________

As a parent/guardian of the above named child, please attempt to contact me at the time of the accident or illness without postponing medical treatment. OTHER INSTRUCTIONS:__________

___________________________________________________________________________ 

As participant of legal age I hereby agree to medical treatment at time of accident or illness without postponing medical treatment until contact of emergency is made.(please initial)_______ ___Every attempt to make contact with emergency will be made by facility _________________________

I HAVE READ THE ENTIRE RELEASE AND AGREE TO IT

PRINT NAME______________________SIGN /DATE_____________________________