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:
 
   
   
     
   

 

City of Elko, 1751 College Avenue, Elko, Nevada 89801
Phone: (775) 777-7110 Fax: (775) 777-7119
email:cityofelko@ci.elko.nv.us
Copyright 2001 City of Elko- All Rights Reserved
Questions or comments with this site?