Fillable Emergency Medical Release Form printable pdf download

Emergency Medical Release Form

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Complete Emergency Medical Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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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: _______________________________________________________

Emergency Medical Release Form

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