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Kinship Medical Release Form

Kinship Medical Release
For 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:
Home 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:
Date
Type name

Kinship Medical Release