MEDICAL & DENTAL RELEASE FORM
FOR MINOR
I, ${input_55_2} . ${input_55_3_3} , certify that I am the parent or legal guardian of the minor listed below, and as such, I hereby convey temporary authority to the below designated adults for the sole purpose of obtaining or arranging any emergency medical or dental care for the minor as may be deemed necessary for the well-being of my when not accompanied by a parent/legal guardian or should either parent/legal guardian be unreachable by telephone.
THEREFORE, I hereby approve and empower the below listed individuals with the authority to arrange and/or consent for any and all emergency medical/dental care and treatment of my in my absence.
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_____________________________
(Signature of Parent/Legal Guardian)
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${input_55_10}
_____________________________
(Date)
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${input_55_3_3}
_____________________________
(Name of Parent/Legal Guardian)
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${input_55_7}
_____________________________
(Relationship to )
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${input_55_121}
_____________________________
(Home/Work Number)
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${input_55_122}
_____________________________
(Cell Number)
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MINOR
Child’s Name: ${input_55_13_3} :
Address: ${input_55_17_1} , ${input_55_17_3} , ${input_55_17_4} ${input_55_17_5}
Telephone Number: ${input_55_123} :
Date of Birth: ${input_55_14} :
Parent/Legal Guardian: ${input_55_3_3}
Address: ${input_55_4_1} , ${input_55_4_3} , ${input_55_4_4}
Home/Work Telephone: ${input_55_121}
Cell Telephone: ${input_55_122}
Allergies:
Medical Conditions:
Current Medications:
PRIMARY CHILD CARE PROVIDER
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${input_55_75}
_____________________________
(Primary Child Care Provider Name)
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${input_55_76}
_____________________________
(Relationship to Minor Child)
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${input_55_77}
_____________________________
(Home/Work Telephone Number)
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${input_55_78}
_____________________________
(Cell Phone Number)
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AUTHORIZED EMERGENCY CONTACTS
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${input_55_90}
_____________________________
(Emergency Contact Name)
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${input_55_91}
_____________________________
(Relationship to Minor Child)
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${input_55_92}
_____________________________
(Home/Work Telephone Number)
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${input_55_93}
_____________________________
(Cell Phone Number)
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HEALTH INSURANCE & DOCTOR INFORMATION
Insurance Company: ${input_55_105}
Policy Number: ${input_55_106}
Group Number: ${input_55_107}
Physician’s Name: ${input_55_118}
Address: ${input_55_119_1} , ${input_55_119_3} , ${input_55_119_4} ${input_55_119_5}
Telephone Number: ${input_55_120}
