Medical Insurance Information

Company: Policy #: _________________

Medical Treatment Authorization

I hereby authorize a representative of Greg Cattrano's Goalie Clinic to take my child to a physician or hospital in case of an emergency.

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(Signature of Parent/Guardian)

__________________ 

(Date)

Waiver and Release We, the undersigned, waive and release and forever dis-charge Greg Cattrano’s Goalie Clinic, The Shipley School, and Mark Duncan for any personal injury or claims for damages which may be sustained or occur during participation in the clinic. I certify that the applicant is in good physical condition to take part in Greg Cattrano’s Goalie Clinic.

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(Signature of Parent/Guardian)

__________________ 

(Date)