Medical Release

I hereby give my permission for any and all medical attention necessary to be administered to my child, in the event of an accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be contacted. I also hereby assume the responsibility for payment of such treatment.

My Name
Address
Telephone Number (Home)
Telephone Number (Work)

My Insurance Co.
My Policy #

In the event I cannot be reached, the following person(s) are so designated:

Contact #1
Name
Address
Telephone Number

Our Family Physician is :
Name
Address
Telephone Number

Known Allergies :
Other Information :
Signed : _____________________________ Date: ___________________

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(717) 337-0609
Email: info@gysc.org

Office Hours:
Tuesday & Friday
1:00 - 3:00 pm