TRF Youth 2022 Medical Release Form

TRF Youth 2022 Medical Release Form

Youth 2022 Medical Release Form
Parent or Legal Guardian's Name*

First NameLast Name
Parent or Legal Guardian's Phone Number*
Please enter a valid phone number.
Child's Name*

First NameLast Name
Child's Birth Date*

MonthDayYear
Date
By agreeing to this form and signing below, I, as the parent or legal guardian of the child listed above, do hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of Table Rock Fellowship staff and volunteer members of Medford, Oregon and I am not reasonably available by telephone to give consent.

I agree that this authorization is effective from January 2022 until December 2022.
Today's Date*

MonthDayYear
Date
Parent or Legal Guardian Signature*

Clear
This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. This additional information will assist in treatment if it can be furnished with the consent form but is not required.
Family Address
Additional Parent/Guardian Name

First NameLast Name
Additional Parent/Guardian Phone
Please enter a valid phone number.
Additional Parent/Guardian Name

First NameLast Name
Additional Parent/Guardian Phone
Please enter a valid phone number.
Child's Last Tetanus Shot

MonthDayYear
Date
Allergies to foods or drugs
Special Medications, Blood Type or Pertinent Information
Child's Physician
Physician's Phone Number
Please enter a valid phone number.
Name of Insurer
Insurance Policy #
Preferred Hospital
Should be Empty: