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MEDICAL & DENTAL RELEASE FORM

FOR MINOR

 

 

I, . , certify that I am the parent or legal guardian of the minor [BF1] [BF2] listed below, and as such, I hereby convey temporary authority to the below designated adults for the sole purpose of obtaining or arranging any emergency medical or dental care for the minor [BF3] [BF4] as may be deemed necessary for the well-being of my [BF5] [BF6] when not accompanied by a parent/legal guardian or should either parent/legal guardian be unreachable by telephone.

THEREFORE, I hereby approve and empower the below listed individuals with the authority to arrange and/or consent for any and all emergency medical/dental care and treatment of my [BF7] [BF8] in my absence.

 

 

 

 

 

 

 

 

(Signature of Parent/Legal Guardian)

 

(Date)

 

 

(Name of Parent/Legal Guardian)

 

 

(Relationship to [BF9]  [BF10] )

 

(Home/Work Number)

 

(Cell Number)

 

 

 

 

 

 

                                                           

 

 

 

 

 

 

 

MINOR

Child's Name:

Address: , ,

Telephone Number:

Date of Birth:

Parent/Legal Guardian:

Address: , ,

Home/Work Telephone:

Cell Telephone:

Allergies:

Medical Conditions:

Current Medications:

 

 

 

 

PRIMARY [BF16] CHILD CARE PROVIDER

 

 

(Primary Child Care Provider Name)

 

 

(Relationship to Minor Child)

 

 (Home/Work Telephone Number)

 

 (Cell Phone Number)

[BF17] 

 

 

 

AUTHORIZED EMERGENCY CONTACTS

 

 

(Emergency Contact Name)

 

 

(Relationship to Minor Child)

 

 (Home/Work Telephone Number)

 

 (Cell Phone Number)

[BF18] 

 

 

 

HEALTH INSURANCE & DOCTOR INFORMATION

 

Insurance Company:

Policy Number:

Group Number:

Physician's Name:

Address: , ,

Telephone Number:

 

 

 


 [BF1]second_child=no:show

 [BF2]second_child=yes:show

 [BF3]second_child=no:show

 [BF4]second_child=yes:show

 [BF5]second_child=no:show

 [BF6]second_child=yes:show

 [BF7]second_child=no:show

 [BF8]second_child=yes:show

 [BF9]second_child=no:show

 [BF10]second_child=yes:show

 [BF11]second_child=no;show

 [BF12]second_child=yes:show

 [D13]second_child=yes:show

 [D14]third_child=yes:show

 [BF15]fourth_child=yes:show

 [BF16]alternate_care_provider=yes:show

 [BF17]alternate_care_provider=yes:show

 [BF18]second_emergency_contact=yes:show

 [BF19]Should this be completed eliminated?