South Appleton Rocker Softball Association - Medical Release Form
WARNING: PROTECTIVE EQUIPMENT CANNOT PREVENT ALL INJURIES A PLAYER MIGHT RECEIVE WHILE PARTICIPATING IN SOFTBALL 

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)  

South Appleton Rocker Association does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference, or religious preference.  
Sign in to Google to save your progress. Learn more
Athlete Name:  *
Athlete Date Of Birth: *
MM
/
DD
/
YYYY
Rockers Age Group
 *
Address of Athlete: *
Home Phone Number: *
Parent/Guardian #1 Name: *
Relationship to Athlete: *
Phone Number to Contact Parent/Guardian #1: *
Parent/Guardian #2 Name:
 *
Relationship to Athlete:
 *
Phone Number to Contact Parent/Guardian #2:
 *
Name of Athlete's Physician: *
Phone Number of Athlete's Physician: *
Address of Athlete's Physician:
 *
Hospital Preference: *
Parent Insurance Information:
(Include all pertinent information: Name of Company, Policy Number, Group ID)
 *
If Parent/Guardian(s) are unable to be reached in case of an emergency
Emergency Contact #1 Name:
 *
Emergency Contact #1 Relationship to Player:
Emergency Contact #1 Phone Number:
 *
If Parent/Guardian(s) are unable to be reached in case of an emergency
Emergency Contact #2 Name:
 *
Emergency Contact #2 Relationship to Player:
Emergency Contact #2 Phone Number:
 *
Please list any allergies/medical problems, including those requiring maintenance medication. (i.e. Medical Diagnosis, Medication, Dosage, & Frequency of Dosage) If your athlete does not have any known allergies and is not taking any medications please write "None" as your response:
 *
Date of Last Tetanus Booster: *
MM
/
DD
/
YYYY

In the event of an emergency when the parent(s)/guardian(s) are not present, coaches will attempt to contact the listed parent(s)/guardian(s). If the coach is unable to reach a parent(s)/guardian(s), the emergency contacts will then be contacted. 

I hereby voluntarily give my consent and authorization to the rendering of such care, including any emergency or non-emergency diagnostic procedure, medical, dental, surgical care and hospitalization that any health care personnel has determined is advisable, in the best judgment of said health care personnel in providing health care to the minor. It is understood this authorization is given in advance of any specific diagnosis, treatment or hospital care being administered.  


By typing my name below, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. *
Today's Date: *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms