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: