Parental Medical Release

MEDICAL RELEASE FORM

We, ____________ and ___________ are the parents of _______, born _______ and _____, born on _______.  We have left our child in the care of the person named below.  In the event of medical emergency, we authorize medical personnel, including physicians, paramedics, nurses, and persons working under their direction to administer whatever treatment is necessary to care for our child.  If necessary, we authorize transport of our child to the nearest appropriate medical facility.  We jointly and severally take full responsibility for payment for all medically necessary services rendered in reliance on this release.

 ___________________                  ___________________________________

______________________(name)      ____________________ (name)


Caretaker: ___________________________________________


Medical Information:

______________________________________________________________________________

Physicians:

Name: _____________________________    Phone: ____________           

Name: _____________________________    Phone: ____________           

Health Coverage

Carrier/Provider: _______________________________      Policy/Member ______________

Emergency Contact:

If we cannot be located, please contact one of the following:

Name: __________________________                      Phone: __________

Name: __________________________________     Phone: __________