"Sample Medical Permission Form"

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SAMPLE MEDICAL PERMISSION FORM
(Please print or type)
Name: ___________________________________________________________ Age: _______ Sex: _______
Last
First
Middle
Address: ___________________________________________________________________________________
Number & Street
City
State
Zip
Date of Birth:
Home phone: (____) _____________________ Parent’s name(s) ___________________________________
Parent’s daytime phone(s): (____) _________________________ (____) _____________________________
Name and phone number of person to be contacted in case of emergency (if parents cannot be reached):
___________________________________________________ Phone: (____) __________________________
School I attend: ______________________________________ School phone: (____) ____________________
School Address: ____________________________________________________________________________
Number & Street
City
State
Zip
School Principal: _____________________________________ Home phone: (____) ___________________
Who is responsible for medical payments? o Individual
o Insurance
If individual, please provide credit card information: o Visa
o MasterCard
__________________________________________________________________________________________
Name on credit card
Exp. Date
Cardholder’s Signature
Medical Insurance Company Name:
State: ________
Policy Number: ____________________________________ Name on Card:
Physician’s Name: ___________________________________ Phone Number: (____) _________________
BRIEF MEDICAL HISTORY
Special Health Condition (list)
Medication and Dosage (if taken)
1.
2.
3.
Additional related information: ______________________________________________________________
Should delegate be restricted from any type of activity? oNo oYes, Explain:
Are you allergic to any medication? o No o Yes If yes, list
A licensed health care provider may provide my child with o Tylenol o Advil o Either o Neither
NOTE: If you are taking medication regularly, you must bring a supply in its original, labeled container.
I, the parent or legal guardian of _______________________ (my child), authorize ___________________________________
to obtain medical care for my child in the event such care is necessary. I understand that, if possible, I will be contacted in
the event my child requires medical attention. I grant to a licensed health care provider or accredited hospital permission
to perform any medical and/or surgical procedures that are essential for the treatment of my child and agree to be
responsible for payment for such care.
I release _________________________________, its employees, and agents from any damages, liability, or loss resulting
from their securing in good faith medical care for my child.
Parent or Guardian Signature: _____________________________________________ Date
SAMPLE MEDICAL PERMISSION FORM
(Please print or type)
Name: ___________________________________________________________ Age: _______ Sex: _______
Last
First
Middle
Address: ___________________________________________________________________________________
Number & Street
City
State
Zip
Date of Birth:
Home phone: (____) _____________________ Parent’s name(s) ___________________________________
Parent’s daytime phone(s): (____) _________________________ (____) _____________________________
Name and phone number of person to be contacted in case of emergency (if parents cannot be reached):
___________________________________________________ Phone: (____) __________________________
School I attend: ______________________________________ School phone: (____) ____________________
School Address: ____________________________________________________________________________
Number & Street
City
State
Zip
School Principal: _____________________________________ Home phone: (____) ___________________
Who is responsible for medical payments? o Individual
o Insurance
If individual, please provide credit card information: o Visa
o MasterCard
__________________________________________________________________________________________
Name on credit card
Exp. Date
Cardholder’s Signature
Medical Insurance Company Name:
State: ________
Policy Number: ____________________________________ Name on Card:
Physician’s Name: ___________________________________ Phone Number: (____) _________________
BRIEF MEDICAL HISTORY
Special Health Condition (list)
Medication and Dosage (if taken)
1.
2.
3.
Additional related information: ______________________________________________________________
Should delegate be restricted from any type of activity? oNo oYes, Explain:
Are you allergic to any medication? o No o Yes If yes, list
A licensed health care provider may provide my child with o Tylenol o Advil o Either o Neither
NOTE: If you are taking medication regularly, you must bring a supply in its original, labeled container.
I, the parent or legal guardian of _______________________ (my child), authorize ___________________________________
to obtain medical care for my child in the event such care is necessary. I understand that, if possible, I will be contacted in
the event my child requires medical attention. I grant to a licensed health care provider or accredited hospital permission
to perform any medical and/or surgical procedures that are essential for the treatment of my child and agree to be
responsible for payment for such care.
I release _________________________________, its employees, and agents from any damages, liability, or loss resulting
from their securing in good faith medical care for my child.
Parent or Guardian Signature: _____________________________________________ Date