FC Freeze Medical Release Form Please fill out the appropriate sections of this information sheet, then click on the send button at the bottom of the page. Medical Release Form 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 treament of the above minor. I have not been given a guardantee as to the results of examination or treatment. I authorize the hosptial 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 medical problems which should be noted Family Physician Phone Name of Parent or Guardian Address City State ZIP Home Phone Work Phone FAX Person Responsible for charges (if different from above) Address City State ZIP Home Phone Work Phone FAX Person to notify if parent/guardian unavailable Home Phone Work Phone FAX Insurance Carrier Policy Number Signature of Parent or Guardian