Medical Release and Emergency Contact Form

Please Note:

Andy’s staff will make every effort to reach you or the designated Emergency Contact Person in the case of an emergency. However, if no one can be reached, by submitting this form you are giving your permission for the Andy’s staff to secure proper medical treatment for your child.

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Parent/Guardian Completing Form

First Name

Last Name

Child's Name

First Name

Last Name

Date of Birth

YYYY

Child's Phone (if applicable)

(###)

###

####

First Parent/Guardian

First Parent/Guardian Name

First Name

Last Name

Relationship to Child

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First Parent/Guardian Cell Phone

(###)

###

####

First Parent/Guardian Home Phone

(###)

###

####

First Parent/Guardian Work Phone

(###)

###

####

Second Parent/Guardian

Second Parent/Guardian Name

First Name

Last Name

Relationship to Child

Home Address (if different from above)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Second Parent/Guardian Cell Phone

(###)

###

####

Second Parent/Guardian Home Phone

(###)

###

####

Second Parent/Guardian Work Phone

(###)

###

####

Additional Emergency Contact

Additional Emergency Contact Name

First Name

Last Name

Relationship to Child

Additional Emergency Contact Cell Phone

(###)

###

####

Additional Emergency Contact Home Phone

(###)

###

####

Medical Information

Primary Care Physician

First Name

Last Name

Primary Care Physician Phone

(###)

###

####

Insurance Company

Policy Number

Are there any allergies, medications or medical conditions that the staff need to know about this child?

If your child has a headache or other mild pain do you give us permission to distribute label-recommended dosages of Tylenol or Ibuprofen?

Yes

Date of Child’s last tetanus shot:

YYYY