ࡱ> /1.@  bjbjFF ,,, 6666666JJ)$R1 666``` 66```66` v#x`0)` L `JJ6666 6`H`JJdV JJGREATER FREEHOLD AREA POP WARNER EMERGENCY MEDICAL TREATMENT AUTHORIZATION FORM As a parent/guardian of , a minor, I hereby authorize the treatment by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger my childs life, cause disfigurement, physical impairment or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. Name of Parent/Guardian: Address: City: State: Zip: Daytime Phone Number: ( ) Evening Phone Number: ( ) Cell Phone Number: ( ) Family Physician: Phone: ( ) Indicate specific medical allergies, chronic illnesses, or other medical conditions that coaches and medical personnel should be aware of: Name of Contact in Case of Emergency: Relationship to child : Daytime Phone Number: ( ) Evening Phone Number: ( ) Cell Phone Number: ( ) This release form is completed and signed of my own free will for the sole purpose of authorizing medical treatment under emergency circumstances in my absence. Signature: Date !",QRS_l5 7 B E L N W X _ ` x y ͻ}pbp}pbpbpbpbpbpXbpbpbpbphgOJQJ^Jhh"C>*OJQJ^Jhh"COJQJ^JhiOJQJ^J hh' CJOJQJ^JaJ hh"CCJOJQJ^JaJ#hXoh"C5CJOJQJ^JaJ#hXohXo5CJOJQJ^JaJhh' 5OJQJ^J#hh"C5CJ(OJQJ^JaJ(#hhE 5CJ(OJQJ^JaJ("!"QRS  8 9 F G b c  P@@gd"C @ P@@gdggd"C P6$gd"C 8@ 6$gd"C @ 6$gd"C  gd'  $ %a$gd'       / 0 T   @^gds7 ^gds7  ^gds7 #gd'  #gd"C gd"C #gd"Cgd"C     - C R   hs7OJQJ^Jhh' >*OJQJ^Jhh' OJQJ^Jhh"COJQJ^Jhh"C>*OJQJ^JT U P#gd' gd"C  P@@gd"C*&P1h:p' / =!"#8$%@@@ "CNormalCJ_HaJmH sH tH DAD Default Paragraph FontViV  Table Normal :V 44 la (k(No List !"QRS89FGbc/0TU00p000p000@00@00p00000000000000 @000 0 0 00 0@00@00 @00 000 0   T   3",Q9xy   ' E s7zOi"CXog6*-H8@\ @@UnknownGz Times New Roman5Symbol3& z Arial"hn&z&G"M M !8Z24  3H)?6*FREEHOLD POP WARNERAnthony ColonnaAnthony ColonnaOh+'0 , H T ` lxFREEHOLD POP WARNERREEAnthony ColonnanthnthNormal Anthony Colonna3thMicrosoft Word 10.0@G@n @14>@l_e#xM՜.+,0 hp|  O   FREEHOLD POP WARNER Title  !"#$%'()*+,-0Root Entry Fc v#x2Data 1TableWordDocument,SummaryInformation(DocumentSummaryInformation8&CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q