Student-Athlete Group Travel Medical Release

Student Information

Name of Student-Athlete

Date of Birth

Age

Grade/Class

Home Address

Parent/Guardian Information

Parent/Guardian Name Contact Phone Number(s) Contact Email

Emergency Contact (other than parent/guardian)

Name Relationship Phone Number

Medical Information

Primary Physician Name Physician Phone Number Health Insurance Company Policy Number List Any Allergies Medications (name, dose, frequency) Other Medical Conditions/Notes

Authorization and Release

I hereby give permission for the above student-athlete to participate in group team travel and authorize medical care as deemed necessary by the trip supervisors and/or medical personnel.

Parent/Guardian Signature Date