AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT FOR MINOR**

I (we)                                                                                       and                                                                          of the city of

                                                                , in the county of                                                    , state of                                 

                                 do hereby state that I am (we are) the natural parent(s) (legal guardian(s)) having legal custody of

                                                                                , a minor, age                           , born                                       ,

19            , who resides with me (us) at                                                                                                                                 

                                                                                                                                                                                                         .

In connection with my (our) child’s participation on the Youth Team for  the Pacific Northwest Rugby Football Union, I (we) authorize the Pacific Northwest Rugby Football Union to consent to any X-ray examination, any anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and to be rendered under, the general or special supervision of any physician or surgeon licensed under the provisions of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the office of the physician, or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is being given to provide the Pacific Northwest Rugby Football Union the ability to give specific consent to any and all such diagnosis, treatment, or hospital care with the aforementioned physician in the exercise of his/her best judgment may deem advisable. This consent is given with the caveat that the need for treatment is immediate and I (we) am not available. I (we) understand that I (we) assume all liabilities and expenses for the above. I (we) waive all claims against the above referred to adult, physicians, hospitals and their employees, ambulatory care, etc., in connection with the decision for immediate care.

This authorization is only valid from January 1st, 2005 to December 31st, 2003 inclusive.

The following is provided:  Home phone:                                                              , Work Phone:                                        

Medical Alert: Allergies:                                                                         , Medications:                                                        

Drug Reactions:                                                                                                                                                                     

Previous Injuries/Illnesses/Surgery:                                                        ,Current Physical Condition:                                 

Insurance: Provider/Policy/ID #:                                                                                                                                          

Name of Primary Physician:                                                                                                   Phone #:                                 

Name of Policyholder (generally the parent):                                                                                                                        

Alternate point of contact: Name                                                                                           , Phone #:                               

Sign by Parent/Legal Guardian                                                                                                Date:                                      

**Non-minors and emancipated minors must still fill out this form and sign for themselves.