EMERGENCY MEDICAL TREATMENT RELEASE FORM

As a parent/guardian, I do hereby auhorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger the life of the student, cause a disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor

Relationship to you

Reason for which release is intended

Address of minor (Street, City, State, Zip)

Home phone of minor

Emergency phone

Family Physician

Physician Phone

Physician Address

List allergies, medication, contacts, or other pertinent information:

Health Insurance Information Company

Policy

Group

Parent or Guardian E-signature (type name)

Date

This Release Form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

St. Joseph Catholic Church

EMERGENCY MEDICAL TREATMENT RELEASE FORM

Parish Office