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 or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.

Date of Players Birth:           /           /                                 Date of last Tetanus Booster:              /           /

                                           Month Day Year                                                                                               Month Day Year

Known allergies of this player, including any allergies to medicine________________________________________________

 Any other medical problems which should be noted ___________________________________________________________ 

Family Physician ___________________________________________ Phone _____________________________________

 Name of Parent/Guardian _______________________________________________________________________________

 Address _____________________________________________________________________________________________

 City/State/Zip _________________________________________________________________________________________

 Phone (Home) _____________________ (Work) _________________________(FAX)_______________________________

 Person responsible for charges (if different from above) ________________________________________________________

 Address _____________________________________________________________________________________________

 City/State/Zip _________________________________________________________________________________________

 Phone (Home) ______________________ (Work) _________________________( FAX)_____________________________

 Person to notify if parent/guardian is unavailable _____________________________________________________________

 Phone (Home) _______________________ (Work) _________________________ (FAX)____________________________

 Insurance Carrier___________________________________________ Policy Number _______________________________

  WAIVER

  I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the GCYSA, its affiliated organizations and sponsors.

  Recognizing the possibility of physical injury associated with YOUTH SPORTS  and in consideration for the GCYSA accepting the registrant for its  programs and activities (the “Programs”)’ I hereby release, discharge and/or otherwise indemnify the GCYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.

 KYSA 2/

Signature of Parent/Guardian __________________________________________________

 Date ________________________________________

GALLATIN COUNTY YOUTH SPORTS ASSOCIATION  ( GCYSA )

P.O. Box 644

Warsaw, KY 41095