As the parent/legal guardian of:
                                                Name of Player:_______________________________________

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:_______________________

Allergies:___________________________________________________________________

Other Medical Conditions:________________________________________________________

Player's Physician:__________________________________ Phone #: (___ )____ -_________

Name of Parent/Guardian:_______________________________________________________

Street Address:_____________________________ City:_______________________ State: TX

Zip Code:________________ Phone # H: (___ )____ -_____ Work #: (___ )____ -_____

Street Address:____________________________ City: ________________________State: TX

Zip Code:________________ Phone # H: (___ )____ -_____ Work #: (___ )____ -______

Person to notify if parent/guardian is unavailable:_____________________________________

Street Address:____________________________ City:________________________ State:___

Zip Code:________________ Phone # H: (___ )____-______ Work #: (___ )____ -______

_________________________________________    (___ )____ -______
Medical and/or Hospital Insurance Co                                     Phone #:

_________________________________________   ________________________________
Policy Holder                                                                Policy Number

Signature of Parent /Guardian:________________________________________ Date:__________________

Sworn to and subscribed before me on the______ day of__________________ , _____________ Yr

Notary Public

My Commission expires