|
MEDICAL RELEASE FORM
I,________________________________(parent/guardian’ sname) herby give permission for any and all medical attention to be administered to my child______________________________ (child'’ name) in the event of accident, injury, sickness, etc. under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for ____________ ___, 2008--____________ ___, 2008
ADDRESS:______________________________________________________________________
INSURANCE COMPANY:_________________________________________________________
POLICY NUMBER:______________________________________________________________
In case I cannot be reached, the following person(s) is/are designated to act on my behalf.
· ____________________________________
· ____________________________________
· A representative of Central Community Ministries, Greenville, SC
KNOWN ALLERGIES_____________________________________________________________
CURRENT MEDICATIONS________________________________________________________
CHILD’S PHYSICIAN:____________________________________________________________
PHYSICIAN’S ADDRESS___________________________________________________________
PHYSICIAN’S PHONE ____________________________________________________________
PARENT/GUARDIAN SIGNATURE__________________________________DATE___________
Subscribed and sworn before me_____day of__________________, 2008
____________________________________
Notary Public Signature and Seal
| 
