Fillable Printable Emergency Release for Treatment

Emergency Release for Treatment

This form should be completed by parents and given to the temporary guardian for use if emergency attention is

required.

(Please print)

We, _______________________________________ and ______________________________________________

(father) (mother)

the parents of __________________________________________________________________________________

_____________________________________________________________________________________________

(names of minor children)

give temporary guardianship of said children to: ______________________________________________________

while we are away from _____________________________ to _____________________________________.

The named guardians have full authority to sign and approve any emergency medical care that the above mentioned

children may require during our absence.

The children’s primary care physician is: ___________________________________________________________

(name and telephone number)

Known allergies include: ________________________________________________________________________

Present medications include:______________________________________________________________________

Should notification be necessary, our address is:

__________________________________________________________________

Telephone:_________________________________________________________

__________________________________________________________________

(signature of father)

__________________________________________________________________

(signature of mother)

__________________________________________________________________

(home address)

Date:______________________________________________________________