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Please Print, Fill up and Email or fill up online here

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

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