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 …………………………………………………………………....
