Medical Release Form Student Athlete's Name * First Name Last Name Parent/Guardian 1 * First Name Last Name Phone * (###) ### #### Email * Parent/Guardian 2 First Name Last Name Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Insurance Company * Policy Number * Family Physician's Name * First Name Last Name Physician's Phone # * (###) ### #### Physician's Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Student Allergies Additional Health Information Please list and explain any other health concerns or conditions that you think the coach should be made aware of. In the event that I am unable to be reached, I designate either of the following individuals as emergency contacts. * First Name Last Name Phone * (###) ### #### * First Name Last Name Phone * (###) ### #### I hereby give permission for any and all medical attention necessary to be administered to my child in the event of an accident, injury, sickness, etc., under the direction of any Eagles coach until such time as I may be contacted. * The release is effective for the time during which my child is participating in or traveling to any event of the Eagles Athletics, and also hereby assume the responsibility for payment of such treatment I agree 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, practices or other activities. I also hold harmless Lighthouse Christian Academy and its affiliates, its directors, organizers, coaches, sponsors, managers, drivers, or any other supervisor appointed for any injury incidental to the activities or transportation to and from these activities. I also give permission for Lighthouse Christian Academy to use my child’s picture for advertising purposes such as flyers or brochures. * My typed name (first and last) serves as my signed agreement to the above statements. Date MM DD YYYY Thank you!
