WEST GENESEE POP WARNER

2007

PARENTS MEDICAL RELEASE

In the event of a medical or traumatic emergency, I hereby grant permission for my

child, __________________________________________ to obtain necessary treatment

at the nearest available hospital or treatment facility. I further agree to hold the hospital,

treatment facility or Pop Warner Football and Cheerleading harmless of liability for granting or making available such treatment.

Note any allergies, medication or medical information we should be aware of:

________________________________________________________________________

________________________________________________________________________.

I understand that I am responsible for the cost of treatment, subject to available Pop Warner insurance coverage and my own medical insurance coverage.

________________________ ___________________

Parent or Guardian Signature Date

________________________________

Parent of Guardian Please Print Clearly

_________________________ ___________________________________

Phone Number during the day Phone Number during Evenings/Weekends

___________________________ _____________________________

Name of Physician Name of Dentist

Primary Insurance Information

Name of Carrier: _____________________

Group Policy #:______________________

I.D. #: _____________________________