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: ..........................................................................................................................................................

............................................................................................................................................................................

EMAIL: ...............................................................................................................................................................

Phone contacts (+ backup relative):

............................................................................................................................................................................

............................................................................................................................................................................

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

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

Date: ...........................................................................

Medical Insurance Info and ID #

(XEROX YOUR MEDICAL CARD IN THE SPACE ABOVE HERE)

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

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