AUTHORIZATION FOR EMERGENCY CARE TO MINOR(S)

TUSLA SPIKES YOUTH RUNNING CLUB

I/We, the undersigned parent(s) or legal guardian(s) of the minor(s) listed below:

Minor: ____________________________ Date of Birth: _____________________

Minor: ____________________________ Date of Birth: _____________________

Minor: ____________________________ Date of Birth: _____________________

do hereby authorize any x-ray examination, anesthetic, dental, medical or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of any coach, assistant coach, officer or representative of the Tulsa Spikes Youth Running Club, whether such diagnosis or treatment is rendered at the office of the physician or dentist, or at a hospital licensed by the State of Oklahoma.

I/We, further authorize the physician or dentist to call in any necessary consultants on his/her discretion. I/We further authorize said physician to exercise his/her best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment.

This consent shall remain effective until 12:00am on the 31^st day of December of the calendar year so noted below, unless sooner revoked in writing, delivered to said physician or dentist or said persons entrusted with the custody, care and control of said minor child/children.

Parent/Guardian Signature: ___________________________ Date: ___________________

Athlete:
Minor’s Allergies:	Medications:
Dr.’s Name:	Dr.’s Phone:
Insurance Information:
Carrier Name:	Employer:
Carrier Phone:	Plan/Policy number:
Parent/Guardian:
Home Phone:	Cell phone/Pager:
Special Instructions: