Garciaparra Baseball Group MEDICAL RELEASE FORM I hereby give permissions of any and all medical attention necessary to be administered to ______________________________ in the event of an accident, injury, sickness, etc., under the direction of the people listed below until such time as I may be contacted. The release is effective for the time during which my child is participating with Garciaparra Baseball Group. I also herby assume the responsibility for the payment of such treatment. Parents Name: ________________________________________________________ Home Address: ________________________________________________________ Home Phone: _______________________Cell _______________________________ Insurance Company:_________________________ Policy # _____________________ Family Physician: _____________________ Dr. # _____________________________ Child’s Allergies: ________________________________________________________ Additional Medical Condition (s) ____________________________________________ IN CASE I CAN NOT BE REACHED, EITHER OF THE FOLLOWING PEOPLE ARE DESIGNATED. Michael Garciaparra 562-824-8973 Ramon Garciaparra 562-691-5073 Tim Blume 310-918-9208 I parent /guardian, herby waive any or all rights, claims for damage arising from injury received while my child is playing, walking, or being transported to games or other activities. I also hold harmless the Recreation Authority, its directors, organizers, coaches, sponsors, managers, or any other supervisor appointed for any injury incidental to use my child’s picture for advertising purposes such as flyers or brochures. Signature of Parent / Guardian: ____________________________________ Date ______________________________
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