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Medical Release for Minor Child
The following medical release form can be very significant to have on file for a minor in case a parent can not be reached at the time of an accident. This will allow the appointed person to go ahead and make decisions that can be significant when a child has an event that requires medical attention.

Free Sample Template
Format: Word PDF
# of Pages: 1
Printable: Yes


Medical Release for Minor Child TemplateForm 2926
Format: Word PDF
Category: School, Administration
Type: Release

Minor Medical Release of Liability

Name: ________________________________________________________________________________________

Has my permission to obtain emergency medical treatment for my child:

_____________________________________________________________________________________________

When I cannot be reached or if a delay of treatment would be dangerous for my child.

Mother or Guardian’s Name: _____________________________________________________________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

Father or Guardian’s Name: ______________________________________________________________________

Phone Number: ________________________________________________________________________________

Email Address: _________________________________________________________________________________

My Insurance Provider: __________________________________________________________________________

Child’s Medical Record Number: ___________________________________________________________________

Preferred Hospital or Treatment Center: ____________________________________________________________

Medications: __________________________________________________________________________________

Allergies: ______________________________________________________________________________________

I hereby understand that I assume all of the financial responsibility for any treatment for the injuries that are sustained by my child while he or she is in your care.

Signature of Parent or Guardian: _________________________________________________ Date: ___/___/_____

Signature of Parent or Guardian: _________________________________________________ Date: ___/___/_____