Medical Release Form For Minors

ADVERTISEMENT

MEDICAL RELEASE FORM FOR MINORS
Minor’s Name: __________________________
Date of Birth: ___________________________Age: ________________________
I, __________________________(parent/legal guardian), give my permission for
____________________________(minor’s name) to participate in all activities
sponsored by ______________________________________(church/organization)
from (dates) __________________, 20__ through ___________________, 20__.
In the event of a medical emergency, I give my permission for
________________________________ (minor’s name) to be treated by an accredited
physician in a professional office, medical clinic or hospital. I therefore designate
_________________________________________ ,or any other adult appointed by
__________________________________ as a chaperone for youth activities of the
________________________________ (church/organization) to act on my behalf in
signing the necessary forms to order appropriate treatment for my child.
_________________________________
_____________________________
Signature of Parent/ Legal Guardian
Relationship to minor
_________________________________
(_____)_______-_______________
Printed name of Parent/ Legal Guardian
Phone
_________________________________
Date
Other emergency contacts________________________________________________
Name, relationship & phone_______________________________________________
________________________________
_____________________________
Insurance Company
Name of primary Insured
________________________________
_____________________________
Group Policy #
Social Security # of primary insured
_________________________________
_____________________________
Allergies to any medications
Chronic/Acute Illness

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go