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 in the event of an accident, injury, sickness or other medical emergency. I request and
authorize 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.
This instrument of consent to authorize medical attention shall be in effect as of the date given below. This shall remain in force only until such time
as I am contacted and able to assume such responsibility for the care of my child. I will be responsible for any and all fees and/or costs incurred as a
result of this authorization.
In signing this document, I also understand that any and all personnel associated with Boilers FC or GLRSA shall not be held liable for any injury
whatsoever my child may sustain in the activities thereof.
In the event that I cannot be reached, or in my absence, I have designated the following individual(s) to make the necessary decisions on my behalf:
Parent or Guardian Signature:
Boilers FC, PO Box 5811, Lafayette, IN | Email us at BoilersFC@gmail.com
Boilers FC Medical Release
Date of last tetanus booster:
Any other medical conditions which should be noted:
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