SAMPLE Medical Treatment Authorization Form

AUTHORIZATION FOR MEDICAL TREATMENT

TO WHOM IT MAY CONCERN:

I, _____________________________ (Parent/Legal Guardian) authorize the representative of the (YOUR LEAGUE OR TEAM NAME) bearing this document to act on my behalf in case my child _____________________________ requires emergency medical or surgical care, provided said representative makes a diligent effort to first contact me and obtain my preferences.  If such efforts to contact me are unsuccessful, I authorize said representative to take such action on my behalf as his/her judgment dictates.

______________________________

Signature of Parent/Legal Guardian

Before me the undersigned authority on this day personally appeared ______________________________, known to be the person whose name is subscribed to the foregoing instrument, and acknowledges to me that he/she executed the same for the purposes and considerations therein expressed and in the capacity therein stated.

Given under my hand and seal of office this _____ day of _______________.

Notary Signature __________________________

Printed Name ____________________________

Family Physician ______________________Phone_______________

Insuance Company ______________________Policy# ____________

Hospital Preference ________________________________________

Allergies and or special medical conditions _____________________

Parent/Guardian Contact Information:

Parent Guardian _________________Home Phone_______________

Mother’s Cell ________________Mother’s Work #_______________

Father’s Cell ________________ Father’s Work #________________

Local Emrgency Contacts:

Name* __________________________Phone ___________________

Name* __________________________Phone ___________________

*Please indicate relationship to player.