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RYAA Basketball
Medical Release
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Note: To be carried by any Regular Season or Tournament Team Manager together with team roster or eligibility affidavit. |
Player: _____________________________________ Date of Birth: _______________
League Name: _______________________________ I.D. Number: _______________
Parent or Guardian Authorization:
In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergency Personnel. ( i.e. EMT, First Responder, E.R. Physician)
Family Physician: ___________________________________ Phone: _______________
Address:___________________________________________________________________
Hospital Preference: _________________________________________________________
Insurance Carrier: ___________________________________________________________
In case of emergency contact:
Name Phone Relationship to Player
Name Phone Relationship to Player
Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)
Medical Diagnosis |
Medication |
Dosage |
Frequency of Dosage |
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The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.
Date of last Tetanus Toxoid Booster: _________________________________________
Mr./Mrs./Ms. ____________________________________________________________
Authorized Parent/Guardian Signature
WARNING: Protective equipment cannot prevent all injuries a player might receive while participating in Soccer.