Medical Release Form

For activities sponsored by Kingsland Foundation Inc

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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