I, _________________________________ (Parent/Guardian Name)
hereby give permission for any and all medical attention to be administered to my child _______________________________________________________ (Child’s Name)
in the event of accident, injury, sickness, etc. Under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective for the period of one year from the date given below.
Address: ________________________________________________________________________________________________________________________________________________
Insurance Company: ______________________________________________________
ID. And Policy Numbers: __________________________________________________

In case I cannot be reached, any of the following persons is designated to act on my behalf:
• __________________________________________________________________
• __________________________________________________________________
• __________________________________________________________________
• __________________________________________________________________

Physician:_______________________________________________________________
Address:________________________________________________________________
Phone: _________________________________________________________________
Known Allergies:_________________________________________________________
Signature (parent/Guardian) ________________________________ Date ___________

Subscribed and sworn before me ______day of _______________________, 20__
_____________________________________
Notary Public