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: