I hereby give my permission for any and all
medical attention necessary to be
administered to _________________________ in
the event of an accident, injury, sickness,
etc., under the direction of the person(s)
listed below, until such time as I may be
contacted. I also hereby assume the
responsibility for payment of such
treatment.
Parent / Guardian's Name:
Address:
Telephone Number (Home):
Telephone Number (Work):
My Insurance Co.:
My Policy #:
In the event I cannot be reached,
the following person(s) are so
designated:
Contact #1:
Name:
Address:
Telephone Number:
Our Family Physician is :
Name:
Address:
Telephone Number:
Allergies :
Additional Information :
Signed :
_____________________________
Date:______________
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