MEDICAL TREATMENT RELEASE FORM

I do hereby authorize the treatment, if unable to make decisions on my own, by a qualified and licensed Medical Doctor in an emergency situation. This authority is granted only after a reasonable effort has been made to reach the emergency contacts listed below.

Name: _______________________________________________________________________

Address: ______________________________________________________________________

(street) (city) (zip)

Emergency Contacts:

Name:_____________________________Relationship:________________________________

Phone:____________________ Cell:______________________ Work:___________________

Health Plan Provider (i.e. Kaiser, Blue Cross. Etc)_____________________________________

Primary Physician:_______________________ Phone No. _____________________________

List allergies, medication or other medical conditions:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

Reason for which release is intended:

Anglican Cursillo Weekend on March 8 - March 11, 2012 at the Holy Redeemer Center, 8945 Golf Links Rd., Oakland CA 94605

Signature:___________________________________________________________________

Date Signed:_________________________________________________________________

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Special Dietary Requirements:

If you need special meals, due to medical reasons, please list below:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

revised 9/1/2011