Medical Release Form
 

To Whom It May Concern

As a parent and/or guardian, I do herewith authorize the treatment by a qualified and licensed doctor of the following minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor:

Relationship to Parent/Guardian:

Dates release is intended: August ________  to August ___________

Family Physician

Physician Name:

Physician’s Phone:

Specific medical allergies, chronic illnesses or other conditions:

Additional Emergency Contact

Contact Name:

Contact Phone:

Release

This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Parent/Guardian Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

Signed: