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 24, 2013 and returning on Saturday, January 26, 2013.
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