Medical Information/photo Release For Volunteers And Minor Children


Medical Information/Photo Release
for Volunteers and Minor Children
Parents/Guardian Name/Volunteer Name
_____________________________________________________ Date ________
Address __________________________________________________________________________________
Minor Child’s:
Name ___________________________________________________________________ DOB ____________
Allergies______________________________________ Medical/Special Problems_______________________
Medical Insurance Information
Name of Insurance Company __________________________________________________________________
Policy/Group ID Number ______________________________________________________________________
Name Phone Number
Family Physician(s)___________________________________________________________________________
Siblings over 18 years________________________________________________________________________
I/We, being the parent(s) or legal guardian(s) of the above named minor children herby appoint MTG
to act in my/our behalf in authorizing unexpected medical care, dental care, and hospitalization
for the above named minor(s) during the period of my/our absences from:
_________________________________through ___________________________________
This document shall be presented to a physician, dentist, or appropriate hospital representative
at such times as unexpected medical care, dental care, and/or hospitalization may be required.
Parent/Guardian /Volunteer
We, the parents can be reached in an emergency:
Place: _________________________________________ Phone: ________________________
Place: _________________________________________ Phone: ________________________
MTG sometimes uses photos from classes/events for use in publicity materials. Children’s names will
be withheld from these materials unless parent consent is obtained. I authorize the use of my/my child’s
photo for publicity purposes.
 Yes, I consent use of my photo/my child’s photo for MTG publicity purposes.
 No, I do not wish for my photo/my child’s photo to be used for MTG publicity.
PO Box 481* Monroe WI 53566 * 608.325.1111*


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal