Medical Authorization Form
V 4.1
USA ULTIMATE
5825 Delmonico Drive, Suite 350, Colorado Springs, CO 80919
Web: www.usaultimate.org Email: sportdevelopment@usaultimate.org Tel: 800-872-4384
Purpose: To enable parents or guardians to authorize the provision of emergency treatment for their
children who are injured or become ill while under the authority of [Name of chaperone] _________________
______________________________________ in the event the parents or guardians cannot be reached.
This acknowledges that we, the undersigned, parent(s) or legal guardian(s) of [Name of participant] _______
______________________________________ recognize the potentially hazardous nature of the sport of
ULTIMATE that an injury might be sustained. These injuries include but are not limited to PERMANENT
DISABILITY, BLINDNESS, PARALYSIS AND DEATH. In the event of such an injury to my child and we (I
or my spouse or guardian) cannot be contacted, we give permission to qualified and licensed EMTs,
physicians, paramedics, certified athletic trainers, and/or other medical or hospital personnel to render
such treatment.
We (I) release USA Ultimate, its employees, its agents, its volunteers and its assigns from any personal
injuries caused by or having any relation to this activity. We (I) understand that this release applies to any
present or future injuries or illnesses and that it binds my heirs, executors and administrators.
This release form is completed and signed of my own free will and with full knowledge of its significance.
I have read and understand all of its terms.
Parent/Guardian:
____________________________________________________________________________________
Name Printed Signature Date Phone
Parent/Guardian:
____________________________________________________________________________________
Name Printed Signature Date Phone
Family Physician:
____________________________________________________________________________________
Name Printed Address Phone
Preferred Hospital:
________________________________________________________
Child’s Medical Insurance Carrier: ______________________________________________________
Name Phone
Emergency Contact:
____________________________________________________________________________________
Name Printed Address Phone
Specific facts concerning child’s medical history including allergies, medications being taken, chronic
illness or other conditions which a physician should be alerted to:________________________________
____________________________________________________________________________________
Completed forms should be given to the chaperone. Chaperones are responsible for keeping
these forms on site at all times. USA Ultimate does not collect these forms (unless otherwise
noted).
NOTE: If this completed form is stored electronically on any device, be sure that
it is stored in a secure manner in order to protect and safeguard the identifying
personal information of the named individual(s) from unauthorized or harmful usage.
