MEDICAL EMERGENCY RELEASE FORM

Emergency Medical Release Form

Child Medical & Emergency Authorization

Child's First name

Child's Last name

Child's Date of Birth

Month

Day

Year

Parent's First Name

Parent's Last Name

Relationship to Child

Phone

Emergency Contact Information

Emergency Contact Name

Emergency Contact Phone Number

Medical Information

Known Allergies

Daily Medication(s)

Additional Medical Information / Conditions

Emergency Medical Authorization

I, the undersigned parent or legal guardian of the child listed above, authorize emergency medical treatment for my child if I cannot be reached in a timely manner.

I understand that reasonable efforts will be made to contact me immediately in the event of an emergency. In the event medical treatment is required, I authorize Triangle Reading Academy staff, emergency personnel, and licensed healthcare providers to secure and administer necessary emergency medical care for my child.

I understand that I am financially responsible for any medical expenses incurred.

Consent & Signature

I certify that the information provided is accurate and complete to the best of my knowledge, and I authorize emergency medical treatment for my child if necessary.

Signature

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Date

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MEDICAL EMERGENCY RELEASE FORM

Emergency Medical Release Form

Emergency Medical Authorization

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