Medical Release Form
Medical Release Form
Parents’ Names:________________________________________________________
Address: ______________________________________________________________
Phone #s: Work __________________________
Cell __________________________
In the event of an emergency or non-emergency situation requiring medical treatment, we, XXXXXXX,
hereby grant permission for any and all medical and/or dental attention to be administered to my children,
in the event of an accidental injury or illness, until such time as I can be contacted. This permission
includes, but is not limited to, the administration of first aid, the use of an ambulance, and the
administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.
State of California
County of _________
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal. Notary Public Signature Notary Public Seal