From: Subject: Medical Release Date: Tue, 15 Jan 2008 11:37:30 -0500 MIME-Version: 1.0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.fysa.com/docs/registration/forms/medical%20release%20form.htm X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3198 Medical Release

MEDICAL RELEASE FORM 

I,_____________________________ (Parent/Guardian's Name) hereby =
give permission for

any and all medical attention to be administered to my child =
____________________________=20

(Child's Name) In the event of accident, injury, sickness, etc., under =
the direction of

the person(s) listed below, until such time as I may be contacted.  I =
also assume the

responsibility for the payment of any such treatment. This release is =
effective for

the period of one year from the date given below.

ADDRESS:            =
______________________________________________________________________

.                   =
______________________________________________________________________

HOME PHONE:         =
______________________________________________________________________

INSURANCE COMP:     =
______________________________________________________________________
=20
POLICY NUMBER:      =
______________________________________________________________________


In case I cannot be reached, any of the following persons is designated =
to act on

my behalf.

     * COACH:          =
___________________________________________________

     * ASST.COACH:___________________________________________________

     * MANAGER:     ___________________________________________________

     * A league representative where my child is playing.

     * Any tournament representative where my child is participating in =
a tournament

PHYSICIAN: ____________________________________________________________

ADDRESS: _____________________________________________________________

PHONE: _______________________________________________________________

KNOWN ALLERGIES:____________________________________________________

SIGNATURE (PARENT/GUARDIAN) ________________________DATE  =
__________________

Subscribed and sworn before me,

this ______ day of __________________ , 200_

________________________________________________
Notary Public