MEDICAL & DENTAL RELEASE/CONSENT AUTHORIZATION

FOR A MINOR

I, [PARENT_NAME], certify that I am the parent/legal guardian of the minor child(ren) listed below, and
as such, I hereby convey temporary authority to the below designated adult(s) for the sole purpose of
obtaining or arranging any emergency medical or dental care for the minor child(ren) as may be deemed
necessary for the well-being of my child(ren), when not accompanied by a parent/legal guardian or should
either parent/legal guardian be unreachable by telephone.

THEREFORE, I hereby approve and empower the below listed individuals with the authority to arrange
and/or consent for any and all emergency medical/dental care and treatment of my child(ren) in my
absence.

[SIGNATURE_PARENT_LEGAL_GUARDIAN] [DOCUMENT_DATE_SIGNED]
(Signature Parent/Legal Guardian) (Date)

[PARENT_NAME] [PARENT_PRIMARY_PHONE]
(Print or Type Name of Parent/Legal Guardian) (Home/Work Number)

[RELATIONSHIP_TO_CHILD] [PARENT_ALTERNATE_PHONE]
(Relationship to Child/ren) (Cell Number)

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 INDIVIDUALS AUTHORIZED TO ARRANGE/CONSENT FOR EMERGENCY
MEDICAL/DENTAL CARE:

[CHILD_CARE_PROVIDER_NAME_1] [RELATIONSHIP_TO_MINOR_CHILD_1]
(Name) (Relationship to Minor Child)

[HOME_OR_WORK_TELEPHONE_1] [CELL_NUMBER_1]
(Home/Work Number) (Cell Number)

[CHILD_CARE_PROVIDER_NAME_2] [RELATIONSHIP_TO_MINOR_CHILD_2]
(Name) (Relationship to Minor Child)

[HOME_OR_WORK_TELEPHONE_2] [CELL_NUMBER_2]
(Home/Work Number) (Cell Number)

[CONTACT_ NAME_1] [CONTACT_ RELATIONSHIP_1]

(Name) (Relationship to Minor Child)

[CONTACT_ PRIMARY_PHONE_1] [CONTACT_CELL_PHONE_1]

(Home/Work Number) (Cell Number)

[CONTACT_ NAME_2] [CONTACT_ RELATIONSHIP_2]

(Name) (Relationship to Minor Child)

[CONTACT_ PRIMARY_PHONE_2] [CONTACT_CELL_PHONE_2]

(Home/Work Number) (Cell Number)

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 MINOR CHILD(REN)

Child’s Name: [MINOR_CHILD_NAME_1]

Address: [MINOR_CHILD_ADDRESS_1] [MINOR_CHILD_CITY_1] [MINOR_CHILD_STATE_1]

[MINOR_CHILD_ZIP_1]

Telephone Number: [MINOR_CHILD_TELEPHONE_NUMBER_1]

Date of Birth: [MINOR_CHILD_DATE_OF_BIRTH_1]

Parent/Legal Guardian: [PARENT_NAME_1]

Address: [PARENT_ADDRESS_1] [PARENT_CITY_1], [PARENT_STATE_1] [PARENT_ZIP_1]

Home/Work Telephone: [PARENT_PRIMARY_PHONE_1]

Cell Telephone: [PARENT_ALTERNATE_PHONE_1]

Allergies: [LIST_ANY_KNOWN_ALLERGIES_1]

Medical Conditions: [LIST_ANY_KNOWN_MEDICAL_CONDITIONS_1]

Current Medications: [LIST_CURRENT_MEDICATION_NAME_1]

Child’s Name: [MINOR_CHILD_NAME_2]

Address: [MINOR_CHILD_ADDRESS_2]

Telephone Number: [MINOR_CHILD_TELEPHONE_NUMBER_2]

Date of Birth: [MINOR_CHILD_DATE_OF_BIRTH_2]

Parent/Legal Guardian: [PARENT_NAME_2]

Address: [PARENT_ADDRESS_2] [PARENT_CITY_2], [PARENT_STATE_2] [PARENT_ZIP_2]

Home/Work Telephone: [PARENT_PRIMARY_PHONE_2]

Cell Telephone: [PARENT_ALTERNATE_PHONE_2]

Allergies: [LIST_ANY_KNOWN_ALLERGIES_2]

Medical Conditions: [LIST_ANY_KNOWN_MEDICAL_CONDITIONS_2]

Current Medications: [LIST_CURRENT_MEDICATION_NAME_2]

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 MINOR CHILD(REN)

Child’s Name: [MINOR_CHILD_NAME_3]

Address: [MINOR_CHILD_ADDRESS_3]

Telephone Number: [MINOR_CHILD_TELEPHONE_NUMBER_3]

Date of Birth: [MINOR_CHILD_DATE_OF_BIRTH_3]

Parent/Legal Guardian: [PARENT_NAME_3]

Address: [PARENT_ADDRESS_3] [PARENT_CITY_3], [PARENT_STATE_3] [PARENT_ZIP_3]

Home/Work Telephone: [PARENT_PRIMARY_PHONE_3]

Cell Telephone: [PARENT_ALTERNATE_PHONE_3]

Allergies: [LIST_ANY_KNOWN_ALLERGIES_3]

Medical Conditions: [LIST_ANY_KNOWN_MEDICAL_CONDITIONS_3]

Current Medications: [LIST_CURRENT_MEDICATION_NAME_3]

Child’s Name: [MINOR_CHILD_NAME_4]

Address: [MINOR_CHILD_ADDRESS_4]

Telephone Number: [MINOR_CHILD_TELEPHONE_NUMBER_4]

Date of Birth: [MINOR_CHILD_DATE_OF_BIRTH_4]

Parent/Legal Guardian: [PARENT_NAME_4]

Address: [PARENT_ADDRESS_4] [PARENT_CITY_4], [PARENT_STATE_4] [PARENT_ZIP_4]

Home/Work Telephone: [PARENT_PRIMARY_PHONE_4]

Cell Telephone: [PARENT_ALTERNATE_PHONE_4]

Allergies: [LIST_ANY_KNOWN_ALLERGIES_4]

Medical Conditions: [LIST_ANY_KNOWN_MEDICAL_CONDITIONS_4]

Current Medications: [LIST_CURRENT_MEDICATION_NAME_4]

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 INSURANCE & DOCTOR INFORMATION

Insurance Company: [HEALTH_INSURANCE_COMPANY_NAME_1]

Policy Number: [HEALTH_INSURANCE_POLICY_NUMBER_1]

Group Number: [INSURANCE_GROUP_NUMBER_1]

Physician’s Name: [PHYSICIAN_NAME_1]

Address: [PHYSICIAN_ ADDRESS_1] [PHYSICIAN_ CITY_1], [PHYSICIAN_ STATE_1]

[PHYSICIAN_ ZIP_1]

Telephone Number: [PHYSICIAN_ TELEPHONE_1]

Insurance Company: [HEALTH_INSURANCE_COMPANY_NAME_2]

Policy Number: [HEALTH_INSURANCE_POLICY_NUMBER_2]

Group Number: [INSURANCE_GROUP_NUMBER_2]

Physician’s Name: [PHYSICIAN_NAME_2]

Address: [PHYSICIAN_ ADDRESS_2] [PHYSICIAN_ CITY_2], [PHYSICIAN_ STATE_2]

[PHYSICIAN_ ZIP_2]

Telephone Number: [PHYSICIAN_ TELEPHONE_2]

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