Medical Release Form printable pdf download

Revised 1-8-2014

Georgia Military College Prep School

MEDICAL RELEASE FORM

AUTHORIZATION TO ADMINISTER MEDICAL TREATMENT

School Year 2014-15

I, _____________________________________, the parent, or guardian, or sponsor of ________________________________________,

(Print Name of Parent or Guardian or Sponsor’s Name)

(Print Name of Student)

a minor child who is a commuting student at Georgia Military College Prep School, living with parent/guardian/sponsor, do hereby give:

My consent, that in the event all reasonable attempts by authorized school personnel to contact me have been unsuccessful, for the Principal of Georgia Military

College Prep School, or his designated representative, to consent on my behalf to any x-ray examination, anesthetic, medical treatment, and hospital care of my minor

child, as fully and effectively as if I were personally present.

I authorize the above-mentioned officials of Georgia Military College to serve in “loco parentis” for the transfer of an authorization of administration of any treatment

deemed necessary for the treatment of my minor child.

I authorize the School Nurses of Georgia Military College to administer medications or treatments to my minor child according to the School Physician’s Standing

Orders/Nurse Protocol.

I will be responsible for any medical or hospital fees or costs associated with the illness or treatment of this minor.

This authorization is granted pursuant to the provision of O.C.G.A. 31-9-2 (2) (4) of the Georgia Medical Consent Law.

Name of Student

_________________________________

_________________________________________

_____________

(Please Print) :

First

Last

Signature of Parent, Guardian, or Sponsor

Date

________________

Allergies:

Medical Conditions:

Medications:

______________________________________________

______________________________________________________________

__________________________________________________________

______________________________________________________________

___________________________________________

__________________________________________________________

_______________________________________________________________

___________________________________________

__________________________________________________________

_______________________________________________________________

__________________________________________

PARENT/GUARDIAN TO NOTIFY IN AN EMERGENCY SITUATION:

Name ______________________________

Relationship __________________

Name ___________________________________

Relationship _______________________

Contact)

First

Last

First

Last

Address _______________________________________

Home Phone __________________

Address ____________________________________________

Home Phone _______________________

_______________________________________

Work Phone ___________________

____________________________________________

Work Phone _______________________

City

State

Zip

City

State

Zip

Cell Phone ____________________

Cell Phone ________________________

Place of Employment _____________________________ Occupation _________________________

Place of Employment _________________________________

Occupation _________________________

Medical Release Form

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