Medical Authorization Form

Health Insurance Company:

Health Insurance Policy Number:

Primary Doctor:

Primary Doctor Phone Number:

Primary Dentist:

Primary Dentist Telephone Number:

Does this athlete wear corrective lenses?

Does the athlete have any allergies?

If you answered yes that the athlete does have allergies, please specify below:

Is your athlete taking any medications?

If you answered yes that your athlete is taking medications, please list the medications and the reason why the athlete is taking the medicine.

Date of last Tetanus Shot: 

I authorize consent to emergency and life-saving care required to preserve life or prevent serious harm.

I authorize stabilizing treatment and transport to a hospital or emergency facility.

I authorize routine emergency procedures as necessary (first aid, wound care, splinting).

I authorize diagnostic procedures (X-ray, CT, ultrasound, blood tests) as required for diagnosis.

I authorize administration of non-prescription medications (acetaminophen, ibuprofen, antihistamine) per recommended dosage.

I authorize administration of epinephrine (EpiPen) in the event of a suspected anaphylactic reaction.

I authorize administration of prescription medications currently listed below (name / dose):

Is there any other medical information about this athlete that we should be aware of?

Acknowledgement, Authorization, and Waiver:

I, the Parent/Guardian of the above athlete, do hereby give permission for my child/athlete to attend and participate in activities sponsored by Rock River United.

• I authorize an adult representative of Rock River United to consent to medical care as detailed above for my child/athlete by a duly-licensed physicianor nurse practitioner. 
• I shall be fully responsible for, and agree to pay for, all costs and expenses incurred in connection with emergency medical services rendered to my child pursuant to this authorization.
• Should it beceome necessary for my child to return home due to medical reasons or otherwise, I agree to assume all transportation costs.
• I agree to assume the risk of and release Rock River United, its staff, and a representative from, any and all injury and liability arising out of or relating to the activities conducted or sponsored by Rock River United.
• My child/athlete may ride in transportation provided by Rock River United in connection with athletic activities.
• I state that the information as provided on this form is correct.

Complete Release and Indemnity Agreement

As parent/guardian for the above-named student-athlete (hereinafter referred to as the Minor") by my execution hereof, I hereby release, hold harmless, indemnify, and discharge RRU, its volunteers, agents, employees, officers, directors, sponsors, and/or coordinators from any and all liability, costs, expenses, attorney fees, claims and settlements arising out of or related to or growing out of treatment or care from nurses, doctors, hospitals, and other
medical units for any and all injuries sustained by Minor related thereto.

Further, I hereby give permission to RRU for the Minor to be transported by approved drivers or vehicles provided by RRU.

I fully understand that this Complete Release and Indemnity Agreement will be binding upon Minor's heirs, executors, administrators, and assigns and that the beneficiaries of the Complete Release and Indemnity Agreement are and will be relying upon my consent on behalf on
behalf of and as parent/guardian for Minor as evidenced by my signature, as an inducement to accepting the Complete Release and Indemnity Agreement.