MEDICAL TREATMENT PERMISSION FORM
Student’s Name ______________________________________
I, ____________________________________, hereby give my permission, consent and authorization for any medical treatment deemed necessary by a hospital or physician. I appoint __________________________________ my lawful agent with power to authorize and consent to the administration of medical treatment during the aforementioned training/competition Home Phone (_______)______________________Alternate Phone (______) ____________ Health Insurance Carrier: _________________________ Other Emergency Contacts: _______ __________________ Please list all allergies, restrictions or health exceptions: ______________________________________________________________________________ This form should be properly signed and turned in at the time of registration. In case of such accident or illness, I give permission for medical treatment to be given to me as deemed appropriate. I will assume responsibility for any medical treatment as deemed appropriate. I will assume responsibility for any medical bills incurred on my behalf.
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Student Signature
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Parent/Guardian (if Participant is under 18)