MEDICAL RELEASE FORM

I,_____________________________ (Parent/Guardian's Name) hereby give permission for any and all medical attention to be administered to my child ____________________________ (Child's Name) In the event of accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below.

ADDRESS: ______________________________________________________________________

________________________________________________________________________________

HOME PHONE: __________________________________________________________________

INSURANCE COMP: ______________________________________________________________

POLICY NUMBER: _______________________________________________________________

In case I cannot be reached, any of the following persons is designated to act on my behalf.

* COACH: ___________________________________________________

* ASST.COACH:______________________________________________

* MANAGER: ________________________________________________

* A league representative where my child is playing.

* Any tournament representative where my child is participating in a tournament

PHYSICIAN: ____________________________________________________________

ADDRESS: _____________________________________________________________

PHONE: _______________________________________________________________

KNOWN ALLERGIES:____________________________________________________

SIGNATURE (PARENT/GUARDIAN) ________________________DATE __________________

Subscribed and sworn before me,

this ______ day of __________________ , 200_

________________________________________________
Notary Public