Please Print, Fill up and Mail

Medical Release Form

For activities sponsored by Kingsland Foundation Inc

Parent Name:                          _________________________________________________

 

 

Contact Phone number:            _________________________________________________

 

 

Contact Email:                        __________________________________________________

 

 

Name of Son/Participant:            __________________________________________________

 

 

Known Medical Conditions, including food or drug allergies (if any):

 

_________________________________________________________________________________

 

 

_________________________________________________________________________________

 

 

 

In the event of an emergency or any situation requiring medical treatment, I ____________________

 

_____________________ hereby authorize permission for any and all medical procedures in the

 

event of an accidental injury or illness, until such time as I can be contacted. This permission

 

includes the administration of first aid, the use of an ambulance and the administration of anesthesia

 

and/or surgery under the recommendation of qualified medical personnel.

 

 

 

 

Signature: _____________________________________   Date: __________________________

 

 

 

Please return to Kingsland Foundation / Tekesta Study Center

4415 SW 88th Avenue Miami, FL 33165

carlosalejano@outlook.com