Parental Consent Medical Release Form

Minor's Information

Full Name

Date of Birth

Address

City/State/Zip

Parent/Guardian Information

Parent/Guardian Name

Relationship to Minor

Phone Number

Emergency Contact

Contact Name

Relationship

Phone Number

Medical Information

Physician Name Physician Phone Insurance Provider Policy Number Allergies/Medical Conditions Medications Other Important Information

Consent and Authorization

I, the undersigned parent/legal guardian, authorize the above named minor to participate in the designated activity/trip and authorize emergency medical treatment as deemed necessary by qualified medical personnel. I understand that every effort will be made to contact me prior to such treatment.

Parent/Guardian Signature

Date