PAL Medical Release Form

	Parent or Guardian Authorization:

	In case of emergency, if our family physician cannot be reached, I/We, hereby authorize (child's name) to be treated by another qualified, licensed physician who is available.

	Family Physician:
	Physician Phone Number:	( )
	Parent Signature
	Parent Signature


	Medical History: Check all appropriate, if your child has had any of the following:
	Heart disease		Rheumatic fever
	Heart trouble		Fainting episodes
	Asthma		High blood pressure
	Allergies		Allergic reactions or medicines
	Liver disease		Kidney disease
	Head injuries		Lung disease
	Broken bones		Joint problems
	Diabetes		Blood disorders
	Other

	Explanation of prior medical problems:


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