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Emergency Medical Treatment Release Form
To Whom It May Concern: As a parent/guardian, I do hereby authorize the treatment of a qualified and licensed Medical Doctor in an emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undo discomfort if delayed. This authority is granted only after a reasonable effort has been made to reach me. Student’s name:__________________________________ Relationship to you:_____________ ________ Address:________________________________________ Phone:_________________________________ Type of activity or school year for which release is intended:______________________________________ _________________________________________________________________________________________ Father _________________________________________________________________________________________ Mother
Where parents can be reached when not at home:
Father____________________________________________________________________________________
Address Phone
Mother____________________________________________________________________________________
Address Phone
FamilyPhysician:___________________________________________Phone:___________________________
Address:__________________________________________________City:____________________________
List allergies, medication, or other pertinent comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
Health Insurance Data:
Company:____________________________________Policy:________________________________________
Group:_______________________________________Contract:_____________________________________
List a neighbor or close relative who will assume care of your child if you cannot be reached:
Name:_______________________________________Phone:________________________________________
Address:_____________________________________ Relationship:__________________________________
This release form is completed and signed of my own free will with the sole purpose of authorizing medical
treatment under emergency circumstances in my absence.
Date:_________________________________________Signed:______________________________________
Attention Parents:
This form should be notarized.
Some medical facilities will only provide treatment if the signature is notarized.
________________________________________Notary This form is to be completed by the parent/guardian who has signed the permission slip
NAME OF TEEN THE FOLLOWING INFORMATION APPLIES TO: ____________________________________________________________ ¾ With respect to the information you have listed on the Medical Treatment Release Form, section –“List allergies, medication, or other pertinent comments”, please explain if these are medications your teen is allergic to OR currently taking. ¾ If they are being taken at the time of the event please describe dosage, any side effects we should be aware of, eating/drinking instructions, etc. Also in this space please disclose any health issues we should be aware of with your teen: ¾ Please CIRCLE any item(s) below that you give St. Mary of the Hills permission to administer to your teen upon their request. We will administer them in accordance with the label directions. If you have specific instructions on administration of these medications, please disclose them on this sheet ¾ List any other information I may need to know here:
PLEASE NOTE: It is your responsibility to notify St. Mary of the Hills Youth Minister if
anything changes!
Signature of
Parent/Guardian__________________________Date___________________________

St. Mary of the Hills Catholic Church
2675 John R.
Rochester Hills, MI 48307
(248) 853-5390

Source: http://www.smoth.org/images/stories/PDF_Files/SMYG/Emergency%20Medical%20Treatment%20Release%20Form.pdf