Medical Release Form

  • Name

  • Children Information

  • NameGenderDOBMedical Issues 
  • Emergency Contact Info

  • Section Break

  • Physician/Hospital Information

  • In case of medical emergency, I give my permission for my child to receive emergency medical treatment as deemed necessary, including transportation and treatment at a hospital or other acute care facility. I certify that the above named individuals are covered by medical insurance. I understand that Peachwood Recreation Club does not maintain any form of medical insurance for club members and their guests. The emergency contact(s) listed above have my permission to authorize transportation for my child(ren) and to give consent or refuse medical treatment until I can be reached.