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Michigan Medical Release Form 1

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This form is provided by Tots Around The Clock in Michigan for the medical information release regarding the medical care and treatment necessary to be administered to the child.

Michigan Medical Release Form 1
Michigan Medical Release Form 1
Medical Release Form
Know all Men by these Presents
That I, __________________________________ a legal resident of the (town, city or country)
of __________________________ State of _______________________ United states of
America; have made, constitute and appointed, and by these presents do make, constitute and
appoint Tots Around the Clock and its employees whose address is 1640 Michigan Avenue
Virginia Beach, Va. 23454 to act in my name, place, and stead to procure and authorize any and
all medical and hospital care and treatment, including major surgery, deemed necessary by a duly
licensed physician in any doctor’s office, medical facility, hospital , or other place, if treatment
or surgery is recommended to be in the best health and welfare of my child or children as named
herein.
NAME:________________________________ DOB__________ AGE____________
NAME:________________________________ DOB__________ AGE____________
NAME:________________________________ DOB__________ AGE____________
Notwithstanding my insertion of a specific expiration date herein, This medical release for shall
become NULL AND VOID after (1) year from the date of issue.
Parent Signature________________________________________ Date_____________
Parent Signature________________________________________ Date______________
Michigan Medical Release Form 1