FC Freeze

Medical Release

As the parent/legal guardian of , I request that in my absence the above-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, Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic 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.

Date of Players birth (Mo./Day/Year)	Date of last Tetanus Booster
Known Allergies of this player, including any allergies to medicine
Any other known medical problems of this player which should be noted
Family Physician	Phone

Name of Parent/Guardian	Cell Phone
Address	City
State	ZIP
Home Phone	Work Phone

Person Responsible for Charges (if different from above)	Cell Phone
Address	City
State	ZIP
Home Phone	Work Phone

Person to Notify if Parent/Guardian Unavailable	Cell Phone
Home Phone	Work Phone

Insurance Carrier	Policy Number
Signature of Parent or Guardian