Home
 
 
My my My my
 
 
 
 
 
 
Old Rochester Youth Lacrosse
 
Release Form for Medical and/or Hospital Treatment
 
 
I ……………………………………………hereby grant permission for the Old Rochester Youth Lacrosse or MBYLL/MBGLL Personnel to administer emergency care on site or at the closest hospital near to our practice, or games (or other such facility) rendered to my child………………………………………… while he/she is under their supervision/care.
 
Parent’s Name: ……………………………………………………………………………………………………………………
 
Address: ……………………………………………………………………………………………………………………………
 
Telephone: (H)……………………….. (W)………………………… Fax ………..........................
 
Email: ....…………………………………………………………………………………………………
 
MEDICAL INSURANCE COVER:
Name of Company and Policy Number: ………………………………………………………………………………….
 
OTHER (Relative or Friend) EMERGENCY CONTACT (list two)
Name                            Relation                         Phone Number                                     Email
 
…………………………………………………………………………………………………………………………………………..
 
Name                            Relation                         Phone Number                         Email
 
…………………………………………………………………………………………………………………………………………..
 
MEDICAL HISTORY: (Fill in the blanks where applicable)
 
Known Allergies ..…………………………………………….............................................
Epilepsy/Seizures .............................................………………………………………...... Diabetes.......................................……………………………………………………….......
Asthma........................................... ………………………………………………………....
Bee Sting sensitivity..................................................……………….............................
Relevant Medical/Surgical History ...............................................................................…………………………………………………………………………………………..................
Daily Medication (name of drug and frequency).............................................................……………………………………………………………………….........................................
Other Medical Information We Should Know:.................................................................
 
DECLARATION
I assume responsibility for any medical bills which may be incurred. I further release (Old Rochester Youth Lacrosse and MBYLL/MBGLL, US Lacrosse and/or their representatives from responsibility for any problems that might arise as a result of medical care and or treatment. This includes all hospital staff and US Lacrosse Staff.
 
DATE: …………………
Parent /Guardian Signature …………………………………………………………………....