St. Rose of Lima Athletic Association

Emergency Treatment Form

As parent and/or guardian of ____________________________, a minor, I herewith authorize treatment by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or -her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Parent/Guardian ______________________________________________________

Address ______________________________________ Phone ________________________

Family Physician _______________________________ Phone ________________________

Dates during which release is granted: From _________________ to __________________

Specific medical allergies, chronic illness or other medical conditions of which staff should be aware: _____________________________________________________________________________

Other contact in case of emergency:

Name ______________________________________________ Phone ______________

Relationship _________________________________________

This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signature:  _______________________________________
                               Father, Mother or Legal Guardian

Date: ___________________________