Player Information and Medical Release Form
Player's Name:______________________________________________________________________Date of Birth:_____________________________
Address: _____________________________________City:________________________________________ State:_______Zip:____________
Email Address(es):_______________________________________________________________________________________________________
EMERGENCY INFORMATION (PLEASE INCLUDE AREA CODE)
Father's Name:______________________Home Phone: _____Work Phone:___________________________
Mother's Name:___________________________Home Phone: ______Work Phone: ___________________________
Father's Cell Phone: Mother's Cell Phone: _________________________________
In an emergency, when parents cannot be reached, please contact:
Name:____________________________Home Phone:____________________________Cell Phone:_________________________
Allergies:_________________________________________________________________________________________________________________________
Other Medical Conditions:____________________________________________________________________________________________________
Player's Physician:_____________________________________________________________Phone:_________________________________________
Medical and/or Hospital Insurance Company: Phone:._________________________________________
Policy Holder: Policy #: Group #:____________________________________________________
PARENT'S APPROVAL AND MEDICAL RELEASE
Recognizing the possibility of physical injury associated with Gaelic Football and in consideration for the New York Minor Board and its affiliates accepting the registrant for participation in its program and activities. I hereby release, discharge and/or otherwise indemnify the New York Minor Board, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.
My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have the manager and /or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.
Signature of Parent ________________ Date: ___________________________________
Can you volunteer time: (Y / N)
Coach:______ Linesmen:_________ Score Keeper:________Fundraise:_______
Dinner Dance Help:_________ Journal:_________ Golf Outing:___________