2021 GHLL Medical Release Form
Please complete fully for each player
Player Name
*
First Name
Last Name
Player Date of Birth
*
-
Month
-
Day
Year
Date
Gender:
Male
Female
Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Relationship to Player
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Name
First Name
Last Name
Relationship to Player
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent or Legal 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 Name
Family Physician Phone Number
Please enter a valid phone number.
Family Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital Preference
Parent Insurance Company
Parent Insurance Policy Number
Parent Insurance Group ID Number
Emergency Contact Information
If parent(s) or legal guardian cannot be reach in case of emergency, please contact:
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Player
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Player
Please list any allergies/medical problems, including those requiring medication (i.e. Diabetic, Asthma, Seizure Disorder)
Medical Diagnosis
Medication
Dosage
Frequency
1
2
3
4
Authorization of Parent/Legal Guardian
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. By clicking "Submit" below you attest that you are an authorized parent or guardian of the above-named child and that the information provided is accurate.
Submit
Should be Empty: