Medical Release Form

  • Per Archdiocese of Detroit policy, a separate Medical Release Form must be on file for EACH child registered. Please fill out the form below completely, click submit, refresh the page and fill out additional forms for other children who will be attending religious education programming at St. Ambrose.

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    • To Whom It May Concern:

      As a parent/Guardian, I do hereby authorize the treatment of a qualified and licensed physician of any condition, which, in the opinion of the physician, is deemed necessary and appropriate. This authority is granted only after a reasonable effort has been made to reach me.
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    • Health Insurance Data:
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    • I further authorize the person who presents the minor to sign the Acknowledgement of Receipt of Notice Privacy Rights that may be presented by the physician or health care facility. 

      This authorization is completed and signed of my own free will with the sole purpose of authorizing medical treatment deemed necessary and appropriate by the treating physician. I acknowledge that it is my responsibility to submit a new form if any of the above information changes.
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    • To receive an email notification that your medical form has been received, you must input your email address in the box below. Thank you.
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