Medical Release Form (Minors)
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MEDICAL RELEASE FORM (MINORS)
Name_________________________________ Date of Birth____________
Parent/Guardian Name (If applicable)________________________________
Address____________________________________________________
Telephone Numbers: Home: _________________ Work:________________
Please indicate another person to contact in the event of an accident
Name________________________________ Phone_________________
Insurance Company_________________________ Policy Number________
Are you presently on any medication? ________________________________
(If yes, please list medication)
Drug Sensitivities______________________________________________
Other Allergies_______________________________________________
Please read the alternative statements below and sign under the one that you choose.
Do Not sign more than one!
1. If my child needs medical attention, it is my wish that I am contacted before any
medical procedures are done on my child, unless immediate treatment is necessary to
save my child’s life or to prevent permanent injury.
Signature of Parent/Guardian_________________________________________________
Date
2. If my child needs medical treatment while participating, it is my wish that the
treatment be begun while efforts are being made to contact me. So that treatment is not
delayed, I consent to any medical procedures that the physician believes needed, on the
understanding that efforts will continue to be made to contact me. I accept
responsibility for all cost related to such treatment.
Signature of Parent/Guardian_________________________________________________
Date
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