Roc City Ballers Medical Release Form

Players Name:*
First Last
Players Address:*
Street Address Address Line 2 City State ZIP Code
Home Phone:*
Date of Birth:*
MM slash DD slash YYYY
Team:*
Parent/Guardian Name:*
First Last
Parent/Guardian Address:*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Home Phone:*
Parent/Guardian Work Phone:
Parent/Guardian Cell Phone:
Physician’s Name:*
Prefix First Last
Physician’s Address:*
Street Address Address Line 2 City State ZIP Code
Physician’s Phone:*
Insurer:*
Policy #:*
Emergency Contact Name:
First Last
Emergency Contact Phone:*
Please comment here any medical concerns or additional information
Electronic Signature (Parent or Guardian):*

I hereby give permission for any and all medical attention necessary to be administered to my child in the event of an accident, injury, sickness, etc. under the direction of the Roc City Ballers coaching staff until such time as I may be contacted. Additionally, I hereby give consent to transport my child to a hospital emergency room and/or for emergency medical care (i.e. diagnosis and treatment) by a licensed physician and/or dentist. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my child.
Today's Date:*
MM slash DD slash YYYY