EMERGENCY RELEASE FORM

I hereby give my consent to (insert name) to authorize medical treatment for my child(ren), __________________________________________________ __________, should it be necessary while my child(ren) is/are in her/his care.

Parent/Guardian Signature & Date ____________________________________

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PHYSICIAN AND INSURANCE INFORMATION

Child's Name:

Child's Physician:

Physician's Address:



Physician's Phone #

Health Insurance Carrier:

Insured's Name:

Policy, group, etc. #