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Emergency Medical release Form

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Emergency Medical Release Form

File Type: Word         Price: $5.99        

                                                                                            

Summary: Protect your company, organization, or event from legal liability by having all employees or participants sign a medical release form. This medical release form also allows medical personnel to perform any necessary procedures in the event medical attention is required as a result of an accident. Simply a must have document for any organization looking to reduce legal exposure.

 

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Emergency Medical Release & Liability Waiver

Participant’s Name__________________________________________________ 

Birth date________________________ 

Street Address __________________________________City _________________________________ Zip___________  

EMERGENCY INFORMATION

Father's Name____________________________ Home Phone (_____)____________ Bus Phone (_____)_________

Mother's Name___________________________ Home Phone (_____)____________ Bus Phone (_____)_________  

In an emergency when parent/guardian cannot be reached, please contact the following:  

Name___________________________________ Home Phone (_____)____________ Bus Phone (_____)____________

Name___________________________________ Home Phone (_____)____________ Bus Phone (_____)____________

Allergies________________________________________________________________

Other Medical Conditions_______________________________________________________________

Physician________________________________ Home Phone (_____)____________ Bus Phone (_____)____________

Medical/Hospital Insurance Company________________________________________ Phone (_____)_______________

Policy Holder's Name_______________________________________ Policy Number_____________________________  

THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE PARTICIPANT CAN PARTICIPATE IN ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON

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