EMERGENCY MEDICAL RELEASE FORM
NAME OF CHILD: _______________________________________________________
LAST
FIRST
MIDDLE
DATE OF BIRTH: ______________________________ SEX: __________________
NAME OF FATHER: _____________________________________________________
NAME OF MOTHER: _____________________________________________________
ADDRESS: _____________________________________________________________
HOME TELEPHONE: ____________________ EMAIL: _________________________
FATHER’S CELL OR BUSINESS: __________________________________________
MOTHER’S CELL OR BUSINESS: _________________________________________
IN THE EVENT THAT MY (OUR) CHILD____________________________ BECOMES ILL OR
SUSTAINS INJURY WHILE IN THE CARE OF THE INTERVENTION CENTER FOR EARLY
CHILDHOOD, WE GIVE OUR PERMISSION TO THOSE IN CHARGE TO TAKE WHATEVER
STEPS ARE NECESSARY. IF IT IS NOT POSSIBLE TO REACH THE PARENT OR THE
PHYSICIAN NAMED TO RECEIVE INSTRUCTIONS FOR THE CHILD’S CARE, CONSENT IS
GIVEN TO ANY LICENSED PHYSICIAN AND/OR SURGEON TO WHOM THE CHILD IS TAKEN
FOR TREATMENT. THEY CAN ADMINISTER DRUGS, MEDICINE AND PERFORM SUCH
SURGICAL PROCEDURES AS HE/SHE THINKS THE EMERGENCY REQUIRES FOR THE RELIEF
OF PAIN AND TO PRESERVE THE LIFE AND HEALTH OF MY (OUR) CHILD.
DATE:___________________________________
SIGNATURE OF PARENT/GUARDIAN: _____________________________________
NAME OF INSURANCE: __________________________________________________
POLICY #___________________ INSURANCE PHONE #_________________
PHYSICIAN TO BE CONTACTED IN CASE OF AN EMERGENCY:
________________________________________________________________________
ADDRESS: _______________________________________________________
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