Fillable Medical Release Form printable pdf download

Medical Release Form

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Complete Medical Release Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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MEDICAL RELEASE FORM

I, _____________________________ (Parent/Guardian's Name) hereby give permission

for any and all medical attention to be administered to my

child_________________________ (Child's Name)

In the event of accident, injury, sickness, etc., under the direction of the person(s) listed

below, until such time as I may be contacted.

I also assume the responsibility for the payment of any such treatment.

This release is effective for the period of one year from the date given below.

ADDRESS:______________________________________________________________

_____________________________________________________________________

HOME PHONE: ________________________________________________________

INSURANCE CO.:______________________________________________________

POLICY NUMBER:_____________________________________________________

In case I cannot be reached, any of the following persons is designated to action my

behalf.

A JGMXT representative where my child is training.

PHYSICIAN: ____________________________________________________________

ADDRESS: _____________________________________________________________

PHONE: _______________________________________________________________

KNOWN ALLERGIES:____________________________________________________

SIGNATURE (PARENT/GUARDIAN)

________________________DATE___________

Subscribed and sworn before me, this ______ day of __________________ , 200__

________________________________________________

Notary Public

Medical Release Form

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