Niners Baseball Medical/Insurance Information
If your child requires medical services, such as prescription medications or emergency evaluations, they will be transported to a local hospital. Payment will be the responsibility of the parent or guardian. In order to provide these medical services, the attending physician will require permission to treat statement and insurance information. Niners Baseball Club Staff will contact you in the event of an emergency.  
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Child's Name (all that are in the program) *
Age Groups (Select all that apply) *
Required
Any allergies? *
By Checking this box, I, the parent/guardian of (Child's Name from above), give permission for emergency transport and medical treatment to be administered, I authorize the release of any medical information to the Niners Baseball Club Staff. I also give permission for the Niners Baseball Club Staff to administer over-the-counter medications, such as Advil or Tylenol. *
Required
Parent/Guardian Electronic Signature (Full Name) *
Today's Date *
MM
/
DD
/
YYYY
Insurance Company *
Policy Number *
Parent/Legal Guardian Phone Number *
City *
State *
ZIP *
Submit
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