Medical Release form


Child's Name
Child's Name
Medical Release
In the event that neither parent can be reached, please list additional emergency contacts below in the order that contact should be attempted. Authorized persons will have to submit a copy of their driver’s license as proof of identification for initial pick up.
Contact #1
Contact #1
Phone
Phone
Contact #2
Contact #2
Phone
Phone
Medical History & Provider Information
I hereby authorize and give permission for City Schoolhouse to seek emergency medical treatment for my child in the event they are unable to reach myself or any other parent, guardian or emergency contact of my child. In furtherance of any treatment decisions to be made for the benefit of my child, I authorize City Schoolhouse to request, obtain, review and inspect any and all information bearing upon my child’s health and relevant to any such decisions to be made respecting such treatment. I also agree that I will be responsible for any financial debt incurred by City Schoolhouse in furtherance of the aforesaid actions. Should the need arise, the following emergency treatment procedure will be followed: • A trained or certified staff member will take whatever immediate steps necessary to stabilize the child’s condition. • If further care is needed, appropriate medical personnel will be contacted (i.e. 911). • The child’s parent or guardian will be notified of the situation as soon as possible. I have read and understand the above outlined emergency care procedures.
Parent/Guardian
Parent/Guardian
Date
Date
Pediatrician
Pediatrician
Pediatrician's phone number:
Pediatrician's phone number: