The Following Medical Release Form Is Required For All Minors printable pdf download

The Following Medical Release Form Is Required For All Minors

The following MEDICAL RELEASE Form is required for ALL MINORS.

Authorization to Consent to Treatment of a Minor

I, as the undersigned parent/guardian of_____________________________, a minor, do hereby

authorize Colorado East Bahá’í Schools Committee, or its designated representative, as agents

for the undersigned, to consent to any and all necessary immediate medical or surgical treatment

deemed advisable by any physician or surgeon licensed under the provisions of the Medical

Practice Act.

This authorization shall remain effective from__________to_________, while my child/ward is

attending the Colorado East Regional Bahá’í School Committee sponsored activity.

Signature of Parent or Guardian:

________________________________________________ Date:_________________________

Home Phone:__________________________ Emergency Phone:_________________________

Medical Insurance: _____Yes _____No

Medical Insurance Company/Policy Number__________________________________________

NOTE: Please provide the following information as applicable:

Any known allergies_____________________________________________________________

Any medications the patient is currently taking _______________________________________

Name and phone number of child’s family physician ___________________________________

Any known reactions to medication ________________________________________________

Date of last tetanus/toxoid inoculation ______________________________________________

The Following Medical Release Form Is Required For All Minors