Emergency Medical Release Form

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Emergency Medical Release Form
In case I/we cannot be reached. I/We the undersigned parent(s)/guardian(s)
of _________________________________, do hereby authorize school officials as
our agent(s) to consent to any diagnostic procedure or medical care which is deemed
advisable by and rendered under the general supervision of any licensed physician
or surgeon.
It is understood that the authorization is given not only in advance of any
specific need for treatment, but is also given to provide authority on the part of our
aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or
hospital care which the physician in the exercise of his/her best judgement may
deem advisable.
This authorization shall remain in effect until the end of the sport season,
unless sooner revoked in writing and delivered to the said agent(s).
Dated____________________________ Home Phone_______________________
_________________________________
Business Phone_____________________
Signature of Mother/guardian
_________________________________
Business Phone_____________________
Signature of Father/guardian
Name of relative or guardian to contact if parent cannot be reached.
_________________________________ Phone number______________________
Name of relative or guardian
Has your child ever had a tetanus shot?________
If so, when?________________________________
Does your child have any allergies, or any other medical history a physician may
need to know? If so, please list. _________________________________________

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