Old Rochester Youth Lacrosse
Release Form for Medical and/or Hospital Treatment
I …Todd Butler…hereby grant permission for the Old Rochester Youth Lacrosse or MBYLL/MBGLL Personnel to administer emergency care on site or at the closest hospital near to our practice, or games (or other such facility) rendered to my child……John Butler…… while he is under their supervision/care.
Parent’s Name: …………Todd and Kate Butler……………………………………………
Address: …8 Winnatuxett Beach Road, Mattapoisett, MA 02739……………………
Telephone: (H)…413 575-1261. (W)…508 758-6633… Fax ………..........................
Email: ....Todd.butler@georgebutleradjusters.com…………
MEDICAL INSURANCE COVER:
Name of Company and Policy Number: …Tufts - ID # 888663173………….
OTHER (Relative or Friend) EMERGENCY CONTACT (list two)
Name Relation Phone Number Email
…Kate Butler……………………Mother………………………………413 335-0036……….. kato.butler@gmail.com
Name Relation Phone Number Email
…………………………………………………………………………………………………………………………………………..
MEDICAL HISTORY: (Fill in the blanks where applicable)
Known Allergies ..…………………N/A……………….............................................
Epilepsy/Seizures ................N/A.........................………………………………………...... Diabetes.............................N/A.....……………………………………………………….......
Asthma...............................N/A....... ………………………………………………………....
Bee Sting sensitivity.............N/A...............................……………….............................
Relevant Medical/Surgical History ...N/A...........................................…………………………………………………………………………………………..................
Daily Medication (name of drug and frequency)..N/A.......................................……………………………………………………………………….........................................
Other Medical Information We Should Know:.................................................................
DECLARATION
I assume responsibility for any medical bills which may be incurred. I further release (Old Rochester Youth Lacrosse and MBYLL/MBGLL, US Lacrosse and/or their representatives from responsibility for any problems that might arise as a result of medical care and or treatment. This includes all hospital staff and US Lacrosse Staff.
DATE: …2-6-20………………
Parent /Guardian Signature …Todd Butler……....
