Medical Treatment Authorization Form - Neptune Township printable pdf download

Medical Treatment Authorization Form - Neptune Township

Neptune Township Medical Authorization Form

As a parent and/or guardian of (child’s name) _________________________, a minor,

I hereby authorize the treatment by a qualified and licensed medical doctor in the event

of a medical emergency which, in the opinion of the attending physician, may endanger

my child’s life, cause disfigurement, physical impairment or undue discomfort if delayed.

This authority is granted only after a reasonable effort has been made to reach me.

Name of Parent/Guardian: _____________________________________________

Address: ___________________________________________________________

City: __________________________ State: _____ Zip code: _________________

Daytime phone #: (

) ________-___________

Phone During Program Time #: (

) ________-___________

Family Physician: _______________________Phone #: (

) ________-_________

Dates during which release is granted: from 7-1-2016 to 7-29-2016

Indicate specific medical allergies, chronic illnesses, other medical conditions or

reasonable accommodations that the staff and medical personnel should be aware of:

______________________________________________________________________

Other person to contact in the case of emergency:

_______________________________

Relationship to child: ___________________________________________

Daytime phone # (

) _________-__________

Evening phone # (

) _________-__________

This release form is completed and signed of my own free will for the sole purpose of

authorizing medical treatment under emergency circumstances in my absence.

Signature: ________________________

Date: _______________________

Please keep completed forms for each child on site.

Medical Treatment Authorization Form - Neptune Township