Sample Medical Permission Form printable pdf download

SAMPLE MEDICAL PERMISSION FORM

(Please print or type)

Name: ___________________________________________________________ Age: _______ Sex: _______

Last

First

Middle

Address: ___________________________________________________________________________________

Number & Street

City

State

Zip

Date of Birth:

Home phone: (____) _____________________ Parent’s name(s) ___________________________________

Parent’s daytime phone(s): (____) _________________________ (____) _____________________________

Name and phone number of person to be contacted in case of emergency (if parents cannot be reached):

___________________________________________________ Phone: (____) __________________________

School I attend: ______________________________________ School phone: (____) ____________________

School Address: ____________________________________________________________________________

Number & Street

City

State

Zip

School Principal: _____________________________________ Home phone: (____) ___________________

Who is responsible for medical payments? o Individual

o Insurance

If individual, please provide credit card information: o Visa

o MasterCard

__________________________________________________________________________________________

Name on credit card

Exp. Date

Cardholder’s Signature

Medical Insurance Company Name:

State: ________

Policy Number: ____________________________________ Name on Card:

Physician’s Name: ___________________________________ Phone Number: (____) _________________

BRIEF MEDICAL HISTORY

Special Health Condition (list)

Medication and Dosage (if taken)

Additional related information: ______________________________________________________________

Should delegate be restricted from any type of activity? oNo oYes, Explain:

Are you allergic to any medication? o No o Yes If yes, list

A licensed health care provider may provide my child with o Tylenol o Advil o Either o Neither

NOTE: If you are taking medication regularly, you must bring a supply in its original, labeled container.

I, the parent or legal guardian of _______________________ (my child), authorize ___________________________________

to obtain medical care for my child in the event such care is necessary. I understand that, if possible, I will be contacted in

the event my child requires medical attention. I grant to a licensed health care provider or accredited hospital permission

to perform any medical and/or surgical procedures that are essential for the treatment of my child and agree to be

responsible for payment for such care.

I release _________________________________, its employees, and agents from any damages, liability, or loss resulting

from their securing in good faith medical care for my child.

Parent or Guardian Signature: _____________________________________________ Date

Sample Medical Permission Form

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