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Sample Medical Release Form

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Medical Release Form Template

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Child Medical Release Form

Name: _________________________________________________________________

Date of Birth: ____/____/____ Date of Last Tetanus Shot: ____/____/____

Allergies: ____________________________________________________________

Other Medical Conditions: _____________________________________________




Primary Physician: ____________________________________________________

Primary Physician’s Phone Number: _____________________________________

Name of Parent / Guardian: ____________________________________________

Street Address: _______________________________________________________

City: _______________________________ State: ________ Zip: ____________

Home Phone: _______________________ Cell Phone: _______________________

Emergency Contact: ____________________________________________________

Street Address: _______________________________________________________

City: _______________________________ State: ________ Zip: ____________

Home Phone: ________________________ Cell Phone: ______________________

Medical Insurance: ____________________________________________________

Phone Number: _________________________________________________________

Policy Holder: ________________________________________________________

Policy Number: ________________________________________________________

As the parent / legal guardian of the above mentioned child. I hereby request that in my absence the above named child will be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists and or medical staff that are duly licensed as Doctors of Medicine or Doctors of Dentistry or other licensed technicians or nurses to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above mentioned minor. I understand that I have not been given a guarantee at to the results of the medical examination or treatment. I hereby authorize the hospital or medical facility to dispose of any specimen or tissue that is taken from the above listed player.

Signature of Parent / Guardian

Sworn to and subscribed before me on the _____ day of _______, Yr ____

Notary Public________________________

Commission Expires: ____/____/______

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