Medical+Release+Form

AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT FOR MINOR CHILDREN

Riverview Hospital Assn. __________________________________________ 410 Dewey St. Student’s Name Wisconsin Rapids, WI 54494 __________________________________________ (715) 423-6060 High School

Parents: This form gives the Riverview Hospital Assn. permission to treat your child in the event of an emergency. This must be filled out and signed by parent/guardian even if the child is 18 or older. Please have your band director return this form as part of the registration process by December 12th.

The undersigned parent/guardian of the above named child, in the event that he/she cannot be contacted through reasonable efforts, does hereby empower and grant to Riverview Hospital Assn. permission to consent to and authorize medical treatment and hospital care and treatment for my above named child/ward. This authorization shall be valid for the period of time commencing on January 22, 2010 and ending on January 23, 2010. I do hereby indemnify and hold harmless the physicians, hospital and other persons who act in reliance upon this authorization.

Executed this ____________ day of ________________________. 2009.

____________________________________________________________________________ Signature of Parent/Guardian

____________________________________________________________________________ Phone number(s) where you can be reached at home or work

____________________________________________________________________________ Allergies of child

____________________________________________________________________________ Medications child is taking

____________________________________________________________________________ Date of last tetanus (DPT, Lockjaw) shot

____________________________________________________________________________ Name of family doctor/pediatrician

____________________________________________________________________________ Phone number of family doctor

____________________________________________________________________________ Name of your heath insurance carrier, ID number and group number