EMERGENCY/MEDICAL RELEASE FORM

As a parent/legal guardian of a participant with the Vallejo Knights Basketball Organization, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or a Doctor of Dentistry.  This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the participant including medical transport.

Player's Name: __________________________________________________

Parent(s)/Guardian(s) Name:________________________________________

*Person(s) to be notified if parent(s) cannot be reached in case of emergency*

Emergency Contact Name: _________________________________________

Emergency Telephone: (____) ______________________

Relationship to Player:_____________________________

Medical/Doctor's Name: ___________________________________________

Medical Number:_________________________________

Medical Provider Telephone: (_____) _________________

Special Condition ________________________________________________

______________________________________________________________

______________________________________________________________

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Parent(s)/Guardian(s) Signature:_____________________________________

Date:__________________________________________

Vallejo Knights Basketball Academy