Medical Release Form printable pdf download

Medical Release Form

I, the undersigned parent or guardian of ___________________________, a minor, do hereby authorize

the Green Lake Bahá’í Conference, or its designated representative, agent(s) for the undersigned, to

consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care

which is deemed advisable by, and is rendered under the general or special supervision of any physician

and surgeon licensed under the provisions of the Medicine Practice Act on the medical staff of a licensed

hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

As the parent/guardian of a minor under the age of 18, I understand that this authorization enables the

Green Lake Bahá’í Conference to arrange medical care for my dependant minor in the event I am

unavailable.

I understand that I am responsible for payment of any and all medical expenses incurred on behalf of my

dependent minor. This authorization shall remain effective from ________ [date] to ________[date],

when my child is attending the Green Lake Bahá’í Conference.

Parent/Guardian Signature: ________________________________Date:___________________

Parent/Guardian Telephone: ______________________________________________________

Emergency Contact Name and Telephone: ___________________________________________

Family Physician Name and Telephone: _____________________________________________

Medical Insurance Company: _____________________________________________________

Policy Number: ________________________________________________________________

Additional Emergency Contact (in the event parent cannot be reached): ___________________

Telephone: ____________________________________________________________________

List Allergies, Handicaps, Limiting Health Conditions, Medications, Reactions to

Medications

Revised June 2013

Medical Release Form