Medical Authorization & Emergency Treatment Consent

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Medical Authorization & Emergency Treatment Consent

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Parent/ Guardian Name: *

Child Full Name: *

Child Full Date of Birth: *

E-mail address: *

Phone *

Preferred Hospital/Medical Facility: *

Primary Physician Name: *

Physician Phone Number: *

Insurance Provider: *

Policy Number:

Parent/Guardian Typed Signature: *

Date: *

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I, the undersigned parent/guardian, authorize Boise Beasts Baseball Academy staff, coaches, or representatives to seek emergency medical treatment for my child if I cannot be reached. This authorization includes, but is not limited to, first aid, emergency transportation, and treatment by licensed medical professionals.

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