Szülői Engedély Orvosi Beavatkozásra
Szülői Engedély Orvosi Beavatkozásra
Szülői Engedély Orvosi Beavatkozásra
in the event of accident, injury, sickness, etc. under the direction of the person(s) listed below, until such
time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This
release is effective for the period of one year from the date given below.
ADDRESS:
___________________________________________________________________________
___________________________________________________________________________________
__
INSURANCE COMPANY:
________________________________________________________________
POLICY NUMBER:
_____________________________________________________________________
In case I cannot be reached, any of the following persons is designated to act on my behalf:
• Coach: __________________________________________
• Manager: ________________________________________
PHYSICIAN:
___________________________________________________________________________
ADDRESS:
____________________________________________________________________________
PHONE:
______________________________________________________________________________
KNOWN ALLERGIES:
___________________________________________________________________
____________________________________
Notary Public