Liberty Girls Lacrosse Club
Medical Release /Info Form
Player _________________ Date of Birth ___/_____/_____
Parent or Guardian Authorization:
In case of emergency, if family physician cannot be reached, I hereby authorize my child
to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R. Physician)
Family Physician: ____________________ Phone: _________________
Address: _________________________________
Hospital Preference: _______________________________
Name: __________________ Phone: ____________Relationship to player ___________
Name: __________________ Phone: ____________Relationship to player ___________
Player's Covering Health Insurance Company_____________ Policy Number___________
Please list any allergies/medical problems, including that requiring
maintenance medication (i.e. Diabetic, Asthma, Seizures)
Medical Diagnosis __________________________________
Medications _______________________________________
Dosage __________________________________________
Frequency of Dosage _______________________________
The purpose of the above listed information is to ensure that medical
personnel have details of any medical problem which may interfere with
or alter treatment.
Date of last Tetanus booster: ____/______/_____
Mr./Mrs./Ms: ________________________________________
Authorized Parent/Guardian Signature
Warning: Protective equipment cannot prevent
all injuries a player might receive while participating in lacrosse.
Medical Release /Info Form
Player _________________ Date of Birth ___/_____/_____
Parent or Guardian Authorization:
In case of emergency, if family physician cannot be reached, I hereby authorize my child
to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R. Physician)
Family Physician: ____________________ Phone: _________________
Address: _________________________________
Hospital Preference: _______________________________
Name: __________________ Phone: ____________Relationship to player ___________
Name: __________________ Phone: ____________Relationship to player ___________
Player's Covering Health Insurance Company_____________ Policy Number___________
Please list any allergies/medical problems, including that requiring
maintenance medication (i.e. Diabetic, Asthma, Seizures)
Medical Diagnosis __________________________________
Medications _______________________________________
Dosage __________________________________________
Frequency of Dosage _______________________________
The purpose of the above listed information is to ensure that medical
personnel have details of any medical problem which may interfere with
or alter treatment.
Date of last Tetanus booster: ____/______/_____
Mr./Mrs./Ms: ________________________________________
Authorized Parent/Guardian Signature
Warning: Protective equipment cannot prevent
all injuries a player might receive while participating in lacrosse.
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