Medical Release Form
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1Medical Release Form
Child’s Information
Child’s Name
Parent or Guardian’s Name
Age
Blood Type
Weight
Medication Allergies
Food Allergies
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My child carries an
EpiPen,
Twinject for treatment of allergic reactions due to food allergies,
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Inhaler
Other Allergies
Medical Conditions / History
Current Medications
Date of last Tetanus Shot
Parent’s or Guardian’s Contact Information
EMAIL:
Parent’s Address
Father’s Mobile #
Mother’s Mobile #
Alternative Phone #
Alternative Contact Name:
Phone#
Alternative Contact Name:
Phone#
Insurance Information
Family’s Doctor Information
Provider
Name
Insured Name
Phone #
Group ID#
Address:
Policy ID#
Is there anything else that we should know about your child:
I, _____________________________ give permission for
child listed above to receive medical
treatment in the event of an emergency, accident, injury or sickness. I give authorization for treatment
to all medical personnel, including licensed physicians, nurses, technicians, emergency responders, and
other medical personnel. I also assume responsibility for the cost of treatment.
Parent’s or Guardian’s Name
Parent’s or Guardian’s Signature
Date
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Parent category: Legal