Emergency Release for Treatment

This form should be completed by parents and given to the temporary guardian for use if emergency attention is required.

(Please print)

We, _______________________________________ and __________________________________ 	 (father)	(mother)

the parents of _______________________________________________________ 	

__________________________________________________________________ (names of minor children)

give tempora ry guardianship of said children to: ______________________________________________________
while we are away from _____________________________   to _____________________________________. The named guardians have full authority to sign and approve any emergency medical care that the above mentioned
children may require during our absence.

The children’s primary care physician is: ___________________________________________________ (name and telephone number)

Known allergies include: _____________________________________________ 	

Present medications include:___________________________________________ 	

Should notification be necessary, our address is:

__________________________________________________________________

__________________________________________________________________ Telephone:_________________________________________________________
__________________________________________________________________ (signature of father)

__________________________________________________________________ (signature of mother)

__________________________________________________________________ (home address)

Date:______________________________________________________________