Home » Enroll a Child » Child Enrollment Forms » Kinship Medical Release Form Kinship Medical Release Form Kinship Medical ReleaseFor the safety of my child: First Last I hereby authorize my child’s mentor: First Last Kinship staff or any other volunteer with Kinship of the Park Rapids Area to secure emergency medical attention for my child, in the event that I cannot be contacted.Our local doctor: First Last At (name of clinic):Clinic phone number:has my permission to release any records that may be needed to treat my child in an emergency.For emergency purposes, I can be reached at:Select OneHomeWorkOtherHome Phone:Work Phone:Other Phone:My closest friend/relative is: First Last Phone number:Relationship:Allergies my child has:Regular medication my child receives:Phobias or fears my child has:Any other important medical information:If you are on Medical Assistance or have insurance or an HMO, please give policy name and number to be used:Signature:DateType name Search for:
