Single Parent Medical Release forms are medical release forms filled by single parents with specific information about the guardian, the persons to contact in case of emergencies and the relationship to the children). They also give general information about the child’s health and allergies. Below is a Sample Single Parent Medical Release Form.
Sample Single Parent Medical Release Form
I _____________________________ (Parent or Guardian) hereby give permission for any medical attention to be administered to my child _____________________ (child’s name) in the event of an accident or any medical emergency under the direction of the person (s) listed below until I am contacted.
Address _____________________________________________________________
Phone__________ Home ____________ Work ________ Cell phone ____________
Child’s Name Medical Condition, Allergies, Medication
_________________ _______________________________________
_________________ _______________________________________
_________________ _______________________________________
In case of any emergency, please contact the following on my behalf:
Contact Person_____________________________________________________
Relationship to Child ____________________________________________
Address __________________________________________________________
Phone ___________________________________________________________
Physician ___________________________________________________________
Address __________________________________________________________
Phone: _____________________________________________________________
Signature (Parent/Guardian) ________________ ___Date ____________________
