As the parent/legal guardian of the child(ren) named below, I hereby give consent for emergency medical or dental care. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my child.

I grant this consent only after every attempt has been made to contact me.

Child’s Name __________________________________ Birth date ______________________

Child’s Name __________________________________ Birth date ______________________

Child’s Name __________________________________ Birth date ______________________

Child’s Name __________________________________ Birth date ______________________

Allergies/Chronic Illnesses/Medications

Emergency Contact ___________________________________________________________________

Insurance Provider ___________________________________________________________________

Group# ______________________________________________________________________

Primary Name on Insurance ____________________________________________________________

Physician’s Name ___________________________________________ Phone # __________________

Signature of Parent/Guardian ____________________________________________________________

Home Phone# ___________________________________ Work Phone# ____________________

Cell Phone # _____________________________________

Please send to:

Foxboro Recreation

40 South St , Foxboro , MA 02035

Medical Release must be on file in order to use the pool