Kentucky Medical Release Form
Download the document to the computer for easy use
There are more pages to preview,Read on

MEDICAL RELEASE FORM
As the parent/legal guardian of _______________________________________________, I request that in my absence the abovenamed 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

/
Month Day

/

Date of last Tetanus Booster

Year

/
Month Day

/____
Year

Known allergies of this player, including any allergies to medicine__________________________________________________
Any other medical problems which should be noted ____________________