Minor Medical Release Form
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4Minor Medical Release Form
Please include a photocopy (front and back) of any medical/card. This is necessary for emergency
medical treatment and if prescription medication is lost or damaged.
Insurance Information
Minor Full Name: ____________________________________________________________________
First
MI
Last
Birthday: ____/____/______
Social Security Number: ______-_______-______ Gender: M
F
Parent or Guardian Name: ______________________________________________________________
First
MI
Last
Relationship to Minor: _________________________________________________________________
Home Phone: (
) _____ - _______
Cell Phone: (
) _____ - _______
Address: ____________________________________________________________________________
City: _____________________________________ State: __________ Zip Code: _______________
Email: ______________________________________________________________________________
Family Physician: ________________________________________
Phone: (
) _____ - _______
Insurance Company: _________________________________ Policy Number: ___________________
Group Number:__________________________________________ Phone: (
) _______ - _______
Insured Name: _______________________________________________ Birthday: _____/_____/_____
First
MI
Last
Social Security Number: ______-_______-______ Preferred Pharmacy: ________________________
If not available in an emergency, please contact: (please provide at least one emergency contact)
Name: __________________________________________________ Phone: (
) _____ - _______
Name: __________________________________________________ Phone: (
) _____ - _______
Name: __________________________________________________ Phone: (
) _____ - _______
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Parent category: Legal