Medical Release Form

Student's Name:*

Parent/Guardian's Name:*

Student's Age:*

Parent/Guardian's Email:*

Student's Email:

Home Phone:*

Primary Cell Phone:*

Work Phone:

Secondary Contact Name:

Secondary Contact Phone:

Secondary Contact Cell Phone:

Doctor's Name:

Doctor's Phone:

Preferred Hospital:

My child has the follow medical conditions that may affect him/her in the car.(If child does not have medical conditions simply type "none")*:

Special Medications:

In the event neither parent nor the doctor listed above can be contacted, I hereby authorize B-SAFE Driving Education LLC or their designee to obtain emergency medical care for my child when, in the opinion of a physician and/or surgeon licensed under the provisions of the Medical Practice Act, such medical care will be for the best interest of the child and should not be delayed pending consent of the parents or family doctor. I understand that B-SAFE Driving Education LLC has insurance which pays for the medical or hospital costs that might be incurred on behalf of my child while in an accident in their car.

As parent or guardian I do understand these terms, agree to them, and acknowledge that all information contain herein has been truthful to the best of my knowledge.
Sign with your mouse or finger(touch devices).


DATE*