AUTHORIZATION FOR MEDICAL
TREATMENT OF MINORS

NAME OF MINOR__________________________________BIRTH DATE______________

IDENTIFY ALLERGIES OR SPECIAL CONDITIONS ______________________________

_______________________________________________________________________

I/WE, BEING THE PARENTS(S) OR LEGAL GUARDIANS(S) OF THE ABOVE NEMED MINOR,
DO HEREBY APPOINT:
NAME ADDRESS PHONE

1. JDYAA Lacrosse Coaching Staff

2.______________________________________________________________________

TO ACT IN MY/OUR BEHALF IN AUTHORIZING UNEXPECTED MEDICAL, SURGICAL CARE
AND HOSPITALIZATION FOR THE ABOVE NAMED MINOR(S) DURING THE PERIOD OF
MY/OUR ABSENCE FROM: MONTH/DAY/YEAR Through MONTH/DAY/YEAR

_______________Through_______________

THIS DOCUMENT SHALL BE PRESENTED TO A PHYSICIAN, DENTIST OR APPROPRIATE
HOSPITAL REPRESENTATIVE AT SUCH TIME AS UNEXPECTED MEDICAL, DENTIST,
SURGICAL CARE OR HOSPITALIZATION MAY BE REQUIRED.

1.______________________________________________________________________

PARENT GUARDIAN SIGNATURE ADDRESS PHONE

______________________________________________________________________
WITNESS SIGNATURE ADDRESS PHONE

2.______________________________________________________________________
PARENT GUARDIAN SIGNATURE ADDRESS PHONE

______________________________________________________________________
WITNESS SIGNATURE ADDRESS PHONE

HOSPITAL COVERAGE FOR THE ABOVE NAMED MINOR(S)

1.______________________________________________________________________

INSURANCE COMPANY I.D. OR CONTRACT NUMBER

FAMILY PHYSICIANS:

1.________________________ 2.________________________

NAME AND NUMBER NAME AND NUMBER