Blue Heat Medical Release Form printable pdf download

Blue Heat Medical Release Form

Medical Treatment Authorization Minor’s Name:

__________________________________________________________

Home Address: _________________________________________________________

Date of Birth:______________________________ Gender: _____________

Medical Information

Primary Care Physician’s Name: ___________________________________________

Phone #: (____)________________

Medical Insurance Provider: __________________________ Policy #: ____________

Allergies to Medications: __________________________________________________

Medical Conditions for which the minor is receiving treatment:

______________________________________________________________________

Prescription Drugs the minor is taking:

______________________________________________________________________

Dosage and Frequency:

______________________________________________________________________

Other pertinent medical information:

______________________________________________________________________

AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S) As custodian of the

aforementioned minor, I grant my authorization and consent for a The Blue Heat Coaches or Staff to

administer general first aid treatment for minor injuries or illnesses. If the injury or illness is severe, I

authorize him or her to seek professional emergency personnel to attend, transport, and treat the minor

and to issue consent for any medical care deemed advisable by a licensed medical professional or

institution. I authorize the designated adult to exercise best judgment upon the advice of medical or

emergency personnel.

Effective Date: 10/01/2015.

Signed this _____day of________, 20___.

Parent / Guardian Signature: _______________________________________

Printed Name: ___________________________________________________

Blue Heat Medical Release Form