Medical Treatment Release Form 

To Whom It May Concern:

As a parent/guardian, I do hereby authorize the treatment by a qualified and licensed Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me.

Name of Minor: _____________________________________ Relationship to you:________________

Reason for which release is intended: Gaylord Right to Life Red Eye Washington DC Trip - leaving Gaylord Thursday, January 26, 2017 and returning on Saturday, January 28, 2017.

Address of Minor:___________________________________________________________________

Phone:_______________________________ Emergency Phone:_____________________________

Family Physician:__________________________________________ Phone:___________________

Address:_________________________________________________ City:_____________________

List any allergies, medications, contacts, or other pertinent comments:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Health Insurance Data:

Company:_____________________________________________ Policy:______________________

Group:______________________________________________ Contract:______________________

This release form is completed and signed of my own free will with the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

This form must be Notarized

Date:______________________  Signed:________________________________________________
                                                                                                                  (Parent or Guardian)

State of:_______________________________ Subscribed and sworn to before me

County of:___________________________ this _________ day of__________________ 20________

                                                                      _________________________________________Notary Public