Medical Release Form / Permission To Treat printable pdf download

Medical Release Form / Permission To Treat

Place Church/Youth Group Logo and Church info here

Medical Release Form / Permission to Treat

Name of Church: _____________________________________ City/State:_______________________

Personal Information:

Name: ______________________________________________________________________________

SS # (optional): ________________________ DOB: _____/_____/_______ Age:______ Gender:______

Address: ____________________________________________________________________________

City: _______________________________________________ State: ________ Zip: _______________

Emergency Contact Information:

Parent/Guardian: _____________________________________________________________________

Home Phone: (_____)________________________ Work Phone: (_____)________________________

SecondaryContact: ______________________________ Relationship: __________________________

Home Phone: (_____)________________________ Work Phone: (_____)________________________

Insurance Information:

*Attach a copy of your insurance card to this form.

Insurance Co.: ____________________ Group#: _______________ Policy#: ______________________

Cardholder: _____________________________ Relationship to Cardholder: ______________________

Insurance Co. Address: ________________________________________________________________

Insurance Co. Phone: (_____)_____________________

Personal Medical Information:

Physician s Name: __________________________________ Phone: (_____)_____________________

Physical Limitations (Asthma, diabetes, allergies, etc.), and/or Special Instructions (Allergic to certain

meds, rare blood type, wears contact lenses, etc.):

______________________________________________________________________

Medical Release Form / Permission To Treat