Please complete the form below. Mandatory fields marked *
List all individuals,including parents/legal guardians, in order of preference, to be contacted in an emergency. If possible, include at least one person other than the parents/legal guardians to be contacted in an emergency and to whom the child can be released. The second phone number column can be left blank.
Release of Child Only:
List all individuals, other than the parents/legal guardians, to whom the child may be released.
I give permission to (Provider's Name), licensed by the Department of Human Service to secure emergency medical and/or emergency surgical treatment for the above named minor child while in care.