Montana Medical Release Form - Free Download
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Montana Medical Release Form
Montana Medical Release Form
Revised 6/21/07
MEDICAL RELEASE FORM
Coach’s copy - to be carried by coach to all games and practices.
Player’s Name_____________________________________________ Home Phone ________________________________
Address__________________________________________________ City/Zip____________________________________
Parent/Guardian Name______________________________________ Relationship________________________________
Parent/Guardian Address____________________________________ City/Zip____________________________________
Parent/Guardian Home Phone________________________________ Work Phone________________________________
Parent/Guardian Home Phone________________________________ Work Phone________________________________
Person To Notify In Case of Emergency __________________________________________________________________________
Home Phone______________________________________________ Work Phone________________________________
Doctor To Notify In Emergency______________________________ Phone_____________________________________
Hospital Preference, if any __________________________________ City_______________________________________
List Any Medical Problems Or Conditions Player Has (include allergies and medications currently taking)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Family Insurance Information:
Insurance Company_______________________________________ Child’s Birth Date___________________________
Address_________________________________________________ City/State/Zip_______________________________
Subscriber Name__________________________________________ Do You Have A Dental Program________________
Subscriber Number________________________________________ Group Number______________________________
Subscriber Address________________________________________ City/Zip___________________________________
I hereby give my consent for all medical care prescribed by a duly licensed Doctor of Medicine for the above minor as his/her parent
or legal guardian. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my
dependent. To the best of the undersigned’s knowledge, all of the above information is true and accurate.
Signed__________________________________________________ Date______________________________________
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