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