DRIP NATION BASKETBALL

DRIP NATION BASKETBALL

Medical Release Form
As the parent/legal guardian of the below named athlete, I request that in my absence the named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player. It is understood and agreed that I hereby assume liability for any and all medical expenses incurred as a result of my child's participation in Drip nation Basketball events, including but not limited to ambulance transport, hospital stays, physician and pharmaceutical goods and services. I grant Drip nation Basketball access to my child's medical records and protected health information as necessary to secure appropriate treatment for my child in my absence as necessary.
Player Information
Player Name

First NameLast Name
Player Date of Birth

MonthDayYear
Date
Player Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother Name

First NameLast Name
Mother Phone Number

Area CodePhone Number
Father Name

First NameLast Name
Father Phone Number

Area CodePhone Number
Emergency Contact & Health Insurance Information
Do you have health insurance ?

YesNo
Parent/Guardian Responsible for charges

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Carrier
Name of Policy Holder
Subscriber ID/Group Number
Card Number / Card Date
Name of Primary Physician / Emergency Medical Care Facility
Known Allergies to player
Other Medical problems that should be noted
Person to notify if parent/guardian is unavailable

First NameLast Name
Phone Number

Area CodePhone Number
Information About The Person Filling Out This Request
I am the duly authorized personal representative of the individual identified above. Below is information regarding my status as the individual’s personal representative:
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Relationship to Player
I have read and agree to the above conditions

YesNo
Authorized Signature

Clear
Date

MonthDayYear
Date
Should be Empty: