Microsoft Word - Medical Release Form.doc
S.A.Y. Yes!? Centers for Youth DevelopmentMEDICAL RELEASEParent’s or Guardian’s Authorization for adult in charge to consent to medical or dental treatment of minor child.The undersigned(Parent or Guardian) who resides at , city of, state of_, and who is a parent or legal guardian of, a minor, age, born_, who resides at, city of_, state ofherein authorizes the adult sponsor of S.A.Y.Yes!?to consent to any x-ray, examination, anesthetic, medical or surgical supervision and on the advice of any physician or surgeon licensed to practice in the state of treatment, when the need for such treatment is immediate, and when efforts to contact me are unsuccessful.Dated thisday of_, year Signature of Parent or Guardian*Social Security No. of Parent or Guardianwho has signed formFamily physician’s name, address, and phone Is there any further information that might help us better care for your child?*The request for the parent/guardian’s social security number is only for emergency purposes. The SSN will be used to verify the parent/guardian’s signature by hospitals or other emergency organizations when an emergency has occurred that involves your child.S.A.Y. YES!? Centers for Youth DevelopmentMedical Release ................
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