Parent’s Medical Release Form
I hereby give my permission for any and all medical attention necessary to be administered to (my
child) ______________________________ in the event of an accident, injury, sickness, etc., under the
direction of the person(s) listed below, until such time as I maybe contacted.
If neither of the person(s) designated below can be contacted, I give permission for the
treatment of my child as may be required and determined by the appropriate health care
professional who is present.
This release is effective from (date)______________________ to _____________________________.
I hereby assume responsibility for payment of such treatment and have attached my child’s
insurance information.
Parents Name: _________________________________________________
Home Address: ________________________________________________
Home Phone Number: ___________________________________________
Work Phone Number: ___________________________________________
Cell Phone: _________________________
My Insurance Company is: _______________________________________
Policy Holder: _________________________________________________
Policy Number: _____________________ Group Number: _____________
In case I cannot be reached, I hereby designate the following people to act on my behalf:
Name: _________________________________________________ Phone:___________________________________
Name: _________________________________________________ Phone:___________________________________
Family Physician: ________________________________________
Address: _______________________________________________
Phone Number: __________________________________________
Known allergies, medications takeing, or other conditions that we should be aware of:
________________________________________________________________________________________________________
_________________________________________________________________________________________________________
______________________________ ______________
Signature of Self or Parent/Guardian Date