Emergency Medical Release Form printable pdf download

Emergency Medical Release Form

In case I/we cannot be reached. I/We the undersigned parent(s)/guardian(s)

of _________________________________, do hereby authorize school officials as

our agent(s) to consent to any diagnostic procedure or medical care which is deemed

advisable by and rendered under the general supervision of any licensed physician

or surgeon.

It is understood that the authorization is given not only in advance of any

specific need for treatment, but is also given to provide authority on the part of our

aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or

hospital care which the physician in the exercise of his/her best judgement may

deem advisable.

This authorization shall remain in effect until the end of the sport season,

unless sooner revoked in writing and delivered to the said agent(s).

Dated____________________________ Home Phone_______________________

_________________________________

Business Phone_____________________

Signature of Mother/guardian

_________________________________

Business Phone_____________________

Signature of Father/guardian

Name of relative or guardian to contact if parent cannot be reached.

_________________________________ Phone number______________________

Name of relative or guardian

Has your child ever had a tetanus shot?________

If so, when?________________________________

Does your child have any allergies, or any other medical history a physician may

need to know? If so, please list. _________________________________________

Emergency Medical Release Form