Utah Academic Decathlon 2006

Medical Release Form

 I, the parent/guardian of _________________________, give
                               (Student)  

_______________________ or _________________________
(Coach)                                               (Coach)

from ________________________________  authority to act in my

 behalf in the event that medical assistance is needed during

the dates of ________________  to ________________.

Our medical insurance company is ______________________.

The policy number is _________________.

Parent/Guardian Signature _______________________________.

Date _______________________.