ROADRUNNER BASKETBALL

MEDICAL RELEASE FORM 2010-2011

Player__________________________________________________________

Address________________________________________________________

City___________________ State_______________ Zip_________________

Emergency Contact___________________________

Phone: H______________ W_____________ Cell_____________

Other Emergency number

Name_____________________________ phone________________________

I hereby give my permission for _______________________ to participate in the ROADRUNNER ATHLETIC PROGRAM. I understand in the event medical treatment is required every effort will be made to contact me. If I can't be reached, I give my permission to give first aid to my child and/or secure the services of a licensed medical care provider to provide the care necessary for my child's well being. I also understand that all medical expenses will be my responsibility.

Insurance Co__________________________________ Policy #__________________

Date of last tetanus shot_____________________

Please list

Medical Problems ________________________________________________________

Medications______________________________________________________________

Medical Allergies _________________________________________________________

Other needed information___________________________________________________

Parent/Guardian Signature:__________________________________________________

Date:_______________