Medical Release Form

Parents’ Names:________________________________________________________
Address: ______________________________________________________________
Phone #s: Work __________________________
Cell __________________________

In an emergency, please contact:__________________________________________

Phone #s: ____________________________________________________________
Or contact: ___________________________________________________________
Phone #s: ____________________________________________________________

Physician.s Name: _____________________________________________________

Address: _____________________________________________________________
Phone #s: ____________________________________________________________
Primary Insurance Company: _________________________________________________________
Phone #s: (________) ________ - _______________ (________) ________ - _______________
Billing Address: ______________________________________________________________________
Policy Holder.s Name:
Address:
Relationship to children:
ID #: ________________________________ Group/Policy #: ________________________

Statement of Consent: (To be signed in the presence of a legalized notary public.)

In the event of an emergency or non-emergency situation requiring medical treatment, we, XXXXXXX,
hereby grant permission for any and all medical and/or dental attention to be administered to my children,
in the event of an accidental injury or illness, until such time as I can be contacted. This permission
includes, but is not limited to, the administration of first aid, the use of an ambulance, and the
administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.

Signature: _____________________________________________ Date: _____________________

State of California
County of _________

On __________ before me, (________________________________), personally appeared XXXXX ,

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.

WITNESS my hand and official seal. Notary Public Signature Notary Public Seal