Gold Medal Swim Club Medical Release – Gold Medal Swim School

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Form filled out Date and time

Personal Information

First Name*

Middle Name(s)

Last Name*

Swimmer's Age*

Birthday*

Street Address*

City*

State*

ZIP Code*

Phone Number*

Email Address*

Any Allergies?

Any medical conditions of which the coach should be aware?

List any medications, including supplements, the swimmer is taking:

Mother's Name

Mother's Phone Number*

Father's Name

Father's Phone Number*

Emergency Contact

First Name*

Last Name*

Relation*

Phone Number*

Medical Release*

I agree to the medical release.

I hereby give my permission for any and all medical attention to be administered to my child, in the event of an accident, injury or sickness under the direction of the person listed below until such time as I may be contacted. This release is effective until revoked by me. I also hereby assume the responsibility for payment of any such medical treatment. In case I cannot be reached, any of the following are designated to approve such treatment: Any Member of the Gold Medal Swim Club Coaching Staff or person designated by the Coaching Staff.

Name of Insurance Company

Subscriber's Name

Policy Number

Group Number

Swimmer's Primary Care Physician

Primary Care Physician's Phone

Name*

First Last

Date*

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