Standard Medical Release Form
A standard medical release form is an important document that indicates your consent for your child to receive medical attention in your absence. Your consent is needed for any child below the age of 18 years in order for them to receive medical attention in times when you are unavailable.
Sample Standard Medical Release Form
Please fill out all the details concerning your child.
Name of child: __________________________ Date of birth: __________________
Address: _______________________________ Zip code: _____________________
State: _________________________________ Location: _____________________
Mother’s name: _________________________ Address: ______________________
Zip code: ______________________________ State: ________________________
Tel no: ________________________________ Mob no: ______________________
Father’s name: __________________________ Address: ______________________
Zip code: ______________________________ State: ________________________
Tel no: ________________________________ Mob no: ______________________
Name of child’s physician: ________________ Location: _____________________
Tel no: ________________________________ Mob no: ______________________
Allergies: Medical treatments Recurring illness
____________________ _________________________ __________________
____________________ _________________________ __________________
I do hereby give my consent for my child to receive medical attention in my absence:
Sig: ________________________________ Date: _________________________
Category: Medical Forms
