First Aid Medical Consent Form
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Child s Physician Name: Address: Phone Number: Child s Allergies: Chronic Health Conditions: Emergency Contacts (In order to be contacted) Name Address Relationship to child Home Phone Cell Phone Do you give permission for child to be released to this person Yes No Name Address Relationship to child Home Phone Cell Phone Do you give permission for child to be released to this person Yes No Name Address Relationship to child Home Phone Cell Phone Do you give permission for child to be released to this person Yes No Parent /Guardian Signature Date (valid for one year).
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