Minor Medical Release Form for Oasis for Kids, Inc.

If my son/daughter requires medical attention on a trip sponsored by the Oasis organization,
I authorize David Duffin or his representative to determine if he/she can be released from your agency’s jurisdiction. Mr. Duffin has our permission to transport our child to a destination that is closer to us for a medical check up, such as an x-ray.

Student: (print) ……………………………………………………………….

Date of Birth: …………………………………………………………………

Address: ………………………………………………………………………

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EMAIL: ………………………………………………………………………..

Phone contacts (+ backup relative):

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Parent or Guardian : (print) …………………………………………………….

Parent / Guardian Signature: …………………………………………………….

Date: …………………………………………………………………………

Medical Insurance Info and ID # ………………………………………………….
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(PLEASE PRINT THIS FORM AT 100%, Page 1 TO 1; FILL IT OUT, XEROX YOUR MEDICAL CARD IN THE SPACE ABOVE, MAKE 3 COPIES, AND MAIL ONE TO THE ADDRESS BELOW)

Oasis for Kids, Inc. – A Non-Profit Corp. – 344 Westline Drive – Alameda, CA 94501