Columbia Youth Lacrosse, Inc. MEDICAL RELEASE FORM (Please complete form legibly) I hereby give permission for any and all medical attention necessary to be administered to (youth sports participant) ______________________in the event of an accident, injury, sickness, etc., under the direction of the people listed below until such time as I may be contacted. The release is effective for the time during which my child is participating in the __________________ (specify league). I also hereby assume the responsibility for payment of such treatment. US Lacrosse membership #: ________________ and Expiration Date: _______________ Parent's Name: ____________________________ Home Address: ______________________________________ Home Phone: ______________________ Work or Cell: ______________________ Insurance Company: ________________________________ Policy #:______________ Family Physician: ________________________ Physician's Phone #________________ Physician's Address: __________________________________________ Child's Allergies: _______________________________________________________ Additional Medical Condition(s) that the coach should know about: ___________________________________________________________________________ IN CASE I CAN NOT BE REACHED, EITHER OF THE FOLLOWING PEOPLE IS DESIGNATED Name____________________________ Phone Number _________________________ Name____________________________ Phone Number _________________________ I parent/guardian, hereby waive any or all rights, claims for damage arising from injury received while my child is playing, walking, or being transported to games or other activities. I also hold harmless the Recreation Authority, its directors, organizers, coaches, sponsors, managers, or any other supervisor appointed for any injury incidental to the activities or transportation to and from these activities. I also give permission for the Recreation Authority to use my child's picture for advertising purposes such as flyers or brochures. Signature of Parent/Guardian _____________________________ Date ______________