 |
Upcoming Youth Events Parish Permission Forms |
 |
Medical Treatment Release Form
As a parent/guardian, I do hereby authorize first aid/medical treatment of my child in the event of an emergency which may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. It is understood that efforts will be made to reach me as soon as reasonably possible.
Name of child: Relationship to you:
Reason for which release is intended:
Address of Child:
Daytime Phone: Emergency Phone:
Family Physician: Office Phone:
Office Address:
List allergies, medication, dietary restrictions, contact, or other pertinent comments:
Health Insurance Data:
Company: Policy Number:
Group Number: Contract:
This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstance in my absence.
I certify that I am the (check one) _____ custodial parent _____ legal guardian of the minor child named above, and I agree to the above terms for myself and for my minor child.
Date: ______________ Signed:
(Parent or Guardian)
State of Subscribed and sworn to before me
County of this day of 20
Notary Public