Medical Release Form


I never travel with kids any where unless they have a completed and signed medical release form. It saved me a major headache several years ago at a Junior Beta Convention. If you travel use one! The form below was adapted from a legal form developed by the National Youth Sports Coaches Association. Believe me, at convention that year, a young student got sick and the hospital was hesitant to do anything until her parents arrived (over 2 hours later). I showed the hospital staff this form and no questions were asked from that point on. She stayed in the hospital for nearly two weeks.

Medical Information

Name _________________________________________Date of Birth _______________
Home Address _____________________________________City____________________
State__________________ Zip_______________
Home Telephone (______) _________________________________
Parent/Guardian Mother ________________________________phone(____)__________
Physician's name __________________________________phone(____)___________
If parents cannot be reached, contact:_________________phone(____)___________
List important medical information and or health problems, allergies,etc.___________
Medical Insurance Company Name ____________________________________
Policy or Group ________________________Verification of Benefits(____)__________
Name of Insured __________________________ Relationship to Student_________

Emergency Medical and Surgical Treatment Form

The patient and others whose signatures are attached below do hereby consent to any and all medical and surgical treatments including anesthesia and operations which may be deemed advisable by his or her physicians and surgeons. The intention hereof being to grant authority to administer and perform all and singularly any examinations, treatments, anesthetics, operations, and diagnostics procedures which may now or during the course of the patient's care be deemed advisable or necessary. We also agree that the patient when admitted is to remain in the hospital until his or her physician recommends the patient's discharge.
In witness of our consent and agreement to the matters stated in the three preceding sentences, we have subscribed our signatures below.

___________________________________ ________________________________

Minor - Patient Parent/ Guardian

Date _________________________________

State of Louisiana, Parish of Calcasieu

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