EMERGENCY MEDICAL TREATMENT RELEASE FORM

EMERGENCY MEDICAL TREATMENT RELEASE FORM
As a parent/guardian, I do hereby auhorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger the life of the student, cause a 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 you*
Reason for which release is intended*
Address of minor*
Home phone of minor*
Emergency phone*
Family Physician*
Physician Phone*
Physician Address*
List allergies, medication, contacts, or other pertinent information:
Health Insurance Information:
Company*
Policy*
Group*
Contract*
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 or Guardian Signature*

Clear
Date*

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