Consent To Treatment of A Minor Form

This acknowledges that I, the parent(s)/person having legal custody/legal guardianship of the student-athlete listed below, do hereby authorize the athletic training at practice(s) and the game(s) to provide the below treatment. ­­­­­­­­­­­

These services are being provided by Cleats vs. Cancer in conjunction with its medical partners, team, and affiliates. 

It is understood that this authorization is given in advance of any specific diagnosis or treatment being required but is given to provide authority to the above-described agent(s) to give specific consent to any and all such diagnosis and treatment, meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable.

This authorization shall remain effective for one (1) year of signature­­­­­­­­ unless sooner revoked in writing by the parent and/or guardian, delivered to Cleats Vs Cancer agents.

contactinfo@cleatsvscancer.com
Mailing AddressPO BOX 88194 Seattle, WA 98138

Cleats vs Cancer is incorporated in Washington State in the Corporations & Charities Division and recognized by the State of Washington Secretary of State Department, as a nonprofit organization.  The U.S. Department of the Treasury Internal Revenue Service (IRS) also recognizes Cleats vs Cancer as a nonprofit organization. The Cleats vs Cancer logo is federally trademarked by the U.S. Patent and Trademark Office.

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