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Preschool Hospital Release

****This form needs to be signed and witnessed by a Notary****

In a life threatening situation, children will be admitted and treated at Hardin Memorial Hospital, Elizabethtown, Kentucky.

However, in less severe situations, where parents can not be reached, it is necessary for the hospital to have a notarized permission form from a parent.

Please take this form to a notary and have your signature witnessed.

I__________________give my permission for _________________

(parent name) (child’s name)

to be treated at Hardin Memorial Hospital.

______________________________________

Parent/Legal Guardian Signature

*****This form needs to be signed and witnessed by a notary******

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