Medical Release Form

Child’s Name: __________________________________________________Age: ____________

Address: ___________________________________City: _______________ Zip: ____________

Parent/Guardian Name(s):___________________________________________________________________________

Home Ph __________________________Work Ph: __________________________________

Cell_____________________________

Emergency Contact: _____________________________ Phone: ______________________

Relationship: _______________________________

Child’s Doctor: ______________________________________Phone: _____________________

Existing Medical Coverage: ____________________________Plan #:_____________________

Known Allergies: __________________________________________________________________________________ (include medicine, food, bee stings, etc.)

Current Medications: __________________________________________________________________________________

__________________________________________________________________________________

_________________________________________________________________________________ (or any related information that would assist in safe treatment)

Medical Release: I hereby permit my child to participate in Say Yes To Tennis summer tennis program. I understand and fully accept that there are risks involved in sports, and that accidents and injuries are common and are ordinary occurrences of sports. I hereby release and hold harmless Say Yes To Tennis, Inc., staff, designated coaches, and program officials and supervisors from all liability, and from all actions or claims that I or my child now or hereafter have for damage or injury to my child, or to any person or property, resulting from the negligence or other acts of any employees or volunteers in connection with my child’s participation.

In case of a medical emergency, I hereby give permission to Say Yes To Tennis staff and volunteers to order treatment for my child. This includes any necessary medical treatment and x-rays. Of course, I understand that an attempt will be made to reach me by phone when a diagnosis is completed. I also understand that all related medical costs are my responsibility.

__________________________________________________________________________________ Parent or Guardian Signature Date

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