Emergency Release For Treatment
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1Emergency Release for Treatment
This form should be completed by parents and given to the temporary guardian for use if emergency attention is
required.
(Please print)
We, _______________________________________ and ______________________________________________
(father)
(mother)
the parents of __________________________________________________________________________________
_____________________________________________________________________________________________
(names of minor children)
give temporary guardianship of said children to: ______________________________________________________
while we are away from _____________________________ to _____________________________________.
The named guardians have full authority to sign and approve any emergency medical care that the above mentioned
children may require during our absence.
The children’s primary care physician is: ___________________________________________________________
(name and telephone number)
Known allergies include: ________________________________________________________________________
Present medications include:______________________________________________________________________
Should notification be necessary, our address is:
__________________________________________________________________
__________________________________________________________________
Telephone:_________________________________________________________
__________________________________________________________________
(signature of father)
__________________________________________________________________
(signature of mother)
__________________________________________________________________
(home address)
Date:______________________________________________________________
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Parent category: Legal