Medical Release Form printable pdf download

MEDICAL RELEASE FORM

In the event of illness, medical emergency, or injury occurring to my child while under

the care of _________________________________ (babysitter or other caregiver), I consent for

appropriate fire department and emergency medical services staff or their designees to render

emergency treatment and/or authorize medical treatment at a hospital, urgent care center, or

other appropriate licensed medical facility or office including examination, X-ray, anesthesia,

medical or surgical diagnostic procedures or treatment that is considered necessary for the

welfare of my child. I further agree to hold the fire department and emergency medical services

staff or their designees as well as hospital, urgent care center, or other appropriate licensed

medical facility or office staff harmless for the administration of such appropriate emergency

assistance in my absence.

It is understood that in the event of a serious illness or injury, reasonable effort to reach

the following people will be attempted.

PHONE NUMBERS FOR PEOPLE TO BE CONTACTED:

(

)

and (

)

NAME:

DATED this

day of

, 20

________________________________

Typed or Printed Name

Relationship to Child

________________________________

Signature

STATE OF FLORIDA

COUNTY OF LAKE

I HEREBY CERTIFY that on this day, before me, an officer duly authorized to administer oaths and take

acknowledgments, personally appeared _____________________________________________, ( ) personally

known to me or ( ) who produced ____________________________________ as identification, to be the person

described in and who executed the foregoing and that ( )he/( )she acknowledged before me that ( )he/( )she executed

the same.

Witness my hand and official seal this _____ day of _____________________, 20_____.

_________________________________________

Notary Public

Medical Release Form