Illinois Medical Release Form For Player
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Emergency Medical Release & Liability Waiver
Participant’s Name____________________________________________________ Birthdate________________________
Street Address ____________________________________City _________________________________ Zip___________
EMERGENCY INFORMATION
Father's Name______________________________ Home Phone (_____)____________ Cell/Bus Phone (_____)____________
Mother's Name _____________________________ Home Phone (_____)____________ Cell/Bus Phone (_____)____________
In an emergency when parent/guardian cannot be reached or is not applicable, please contact the following:
Name_____________________________________ Home Phone (_____)____________ Cell/Bus Phone (_____)____________

Name________________________________ Home Phone (_____)____________ Cell/Bus Phone (_____)____________
Allergies____________________________________________________________________________________________
Other Medical Conditions__________________________________________________________