RLB Medical Release

HIGHLIGHTED FIELDS ARE REQUIRED AND SIGNATURE MUST BE SAVED

PARENT OR GUARDIAN AUTHORIZATION

If Parent(s)/Guardian(s) Cannot Be Reached In Case Of Emergency, Contact

Please list any allergies/medical problems, including those requireing maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)

The purpose of the above listen information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

SIGN THE FORM

Electronic Signature

SAVE

CLEAR

Use your mouse or finger(if on touch screen device) to sign the document on the line above.

Please Answer the Security Question to Submit your Form.

3 + 5 =