LONG VALLEY RAIDERS FOOTBALL

EMERGENCY TREATMENT AUTHORIZATION FORM

To Whom It May Concern:

As a parent and/or guardian of ____________________________________, a minor, I hereby authorize the treatment by a qualified and licensed medical doctor in the event of a medical emergency, which, in the opinion of the attending physician, may endanger my child’s life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Parent/Guardian _________________________________________________

Address _______________________________________________________________

City ________________________________________ State ________ Zip _________

Daytime Phone #: ( ) _______ - ______________

Evening Phone #: ( ) _______ - ______________

Family Physician: _________________________ Phone #: ( ) _____ - __________

Dates during which release is granted: From ____________ To ___________

Indicate specific medical allergies, chronic illnesses, or other medical conditions coaches and medical personnel should be aware of:

Other person to contact in case of emergency: ________________________________

Relationship to child _____________________________________________________

Daytime Phone #: ( ) ______ - _____________

Evening Phone #: ( ) ______ - _____________

This release form is completed and signed of my own free will for the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signature ______________________________ Date ________________________