Medical Release Authorization Form For Minor printable pdf download

Medical Release Authorization Form for Minor

Coding Academy 2015, Florida Gulf Coast University

FULL LEGAL NAME: ___________________________________________________________________________

HOME ADDRESS: _____________________________________________________________________________

DATE OF BIRTH: _____________________________________

PHYSICIAN’S NAME AND LOCATION OF THE PRACTICE: _______________________________________________

___________________________________________________________________________________________

PHYSICIAN’S PHONE # (IF KNOWN): (_ _ _ _) __________________________

MEDICAL INSURER/HEALTH PLAN: ___________________________________

POLICY #:__________________

ALLERGIES TO MEDICATIONS: ___________________________________________________________________

ALLERGIES (OTHER): ___________________________________________________________________________

PLEASE NOTE ALL CONDITIONS FOR WHICH THE CHILD IS CURRENTLY RECEIVING TREATMENT:

___________________________________________________________________________________________

NOTE ANY OTHER SIGNIFICANT MEDICAL INFORMATION:

___________________________________________________________________________________________

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)

I do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent

for

_________________________________________________________________

(hereafter “Designated

Adult”) to administer general first air treatment for any minor injuries or illnesses experienced by the Minor. If

the injury or illness is life threatening or in need of emergency treatment, I authorize the Designated Adult to

summon any and all professional emergency personnel to attend transport, and treat the minor and to issue

consent for any X-ray, anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or

hospital care deemed advisable by, and to be rendered under the general supervision of, any licensed physician,

surgeon, dentist, hospital, or other medical professional or institution duly licensed to practice in the state in

which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care.

It is understood that this authorization is given in advance of any such medical treatment, but is given to provide

authority and power on the part of the Designated Adult in the exercise of his or her best judgement upon the

advice of any such medical or emergency personnel.

PARENT /LEGAL GUARDIAN’S NAME: _________________________ RELATIONSHIP TO CHILD: _____________

PARENT/LEGAL GUARDIAN SIGNATURE: _________________________________

DATE: ______________

Medical Release Authorization Form For Minor