Weatherford Christian School

MEDICAL TREATMENT RELEASE FORM

To Whom It May Concern:

As parent/guardian of the below named player, I request that in my absence the player be admitted to any
hospital or medical facility for diagnosis and treatment. 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 diagnostic procedures, treatment procedures, operative procedures and x-ray treatments
of the below named minor as deemed necessary and appropriate. This authority is granted only after a
reasonable effort has been made to reach me.

Name of Minor: Relationship to you:

Date of minor’s birth: Last Tetanus Booster:

Name of Parent/Guardian: Phone #

Address: City:

Emergency Contact: Name: Phone:

Family Physician: Phone:

Physician Address: City:

List allergies, medication, contract, or other pertinent comments:

Health Insurance Data:

Company: Policy:

Group: Contract:

I further authorize the person who presents the minor to sign the Acknowledgment of Receipt of Notice
Privacy Rights that may be presented by the physician or health care facility.

This authorization is completed and signed of my own free will with the sole purpose of authorizing medical
treatment deemed necessary and appropriate by the treating physician.

Signed:
(Parent or Guardian) Date

Sworn to and subscribed before me on the day of , 20 .

Notary Public

Commission Exp.