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PERMISSION FOR MEDICAL TREATMENT, RELEASE OF MEDICAL INFORMATION AND PAYMENT OF MEDICAL EXPENSE I REQUEST AND GIVE PERMISSION to the physicians and medical staffs to treat the above-named participant appropriately, including hospitalization, prescribing medication, and performing emergency medical procedures. I AUTHORIZE release of any medical information to a doctor which may be pertinent to any diagnosis or treatment of the above-named participant. I UNDERSTAND that any charges resulting from this medical treatment will be billed to me at my address or to my medical insurance carrier which is:

Name and Phone Number of Individual(s) to Contact in Case of Emergency Waiver: My son/daughter has been examined by a physician in the last year and is in good health. I hereby authorize Minnesota Storm coaches to act for me, according to its best judgment in any medical emergency, and I hereby waive and release said camp from any liability for injuries or illness incurred by my son/daughter while attending camp.

NOTE!!! The Minnesota Training Center/Minnesota Storm does NOT carry group medical coverage for this program.

Please make checks payable to: Minnesota Training Center

Send application and deposit to:

Athletic Department

Minnesota Training Center

2211 Riverside Ave

Campus box 313

Minneapolis, MN 55454

For additional information contact Brian Graham (816) 392-4954, Mike Tschida (763) 496-7706 or email us directly at mntrainingcenter@gmail.com.


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