RD MX Training Medical Release Form

I, ________________________ (Parent/Guardian's Name) hereby give permission

for any and all medical attention to be administered to my child ____________________

(Child's Name) In the event of accident, injury, sickness, etc., under the direction of

Rodney P Densford Jr., until such time as I may be contacted. I also assume the

responsibility for the payment of any such treatment. This release is effective for

the period of one year from the date given below.

ADDRESS: _____________________________________________________________________

_____________________________________________________________________

HOME PHONE:________________________________________________________

INSURANCE CO.:______________________________________________________

POLICY NUMBER:_____________________________________________________

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In case I cannot be reached, the following person is designated to act on my behalf.

Rodney P Densford Jr. Owner, RD MX Training
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PHYSICIAN: ____________________________________________________________

ADDRESS: _____________________________________________________________

PHONE: _______________________________________________________________

KNOWN ALLERGIES: ____________________________________________________

SIGNATURE (PARENT/GUARDIAN) ________________________DATE___________

Subscribed and sworn before me,

this ______ day of __________________ , 200__________

________________________________________________
Notary Public