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Release Form
This is our Hawley Alliance Youth Release form.
Students name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Grade *
Parent(s) Name *
Your answer
Parent Contact Number *
Your answer
Health Insurance Company
Your answer
Insurance ID#
Your answer
Group #
Your answer
Physician's Name
Your answer
Phone Number
Your answer
Emergency Contact Person *
Your answer
Number for Emergency Contact *
Your answer
Emergency Contacts Relationship to Minor *
Your answer
Health problem we should know about? Medications, Allergies?
Your answer
Activities they should not engage in?
Your answer
I understand and hereby authorize adult workers with Hawley Alliance Youth Ministries to consent to any examination, x-ray, anesthetic, medical or surgical diagnosis to treatment and hospital care which is rendered under supervision of any physician or surgeon licensed under the provisions of Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physicians or at said hospital. Further, as parent or guardian of the minor, I do hereby expressly consent that my son/daughter may receive emergency medical treatment from any physician, hospital, or other medical center without the necessity of first notifying me, and do further agree to hold blameless any physician, hospital, or other medical center for rendering such services. *
Required
Electronic Signature of Parent/Guardian *
Your answer
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