Stroke and Brain Injury Services AbilityPath Stroke and Brain Injury Services – Medical Release Form If you are human, leave this field blank.Student Name *Address *Date *Please Note:Should an accident or illness occur, it may be necessary to provide for local emergency medical service for clients participating in any therapy services at AbilityPath Brain Injury Rehabilitation Services. Please indicate your permission for such treatment by completing and signing the form below. In case of emergency, AbilityPath Brain Injury Rehabilitation Services is authorized to call 911 for emergency services. If it should be necessary for an ambulance to be obtained, I will assume payment of such a bill. Client Signature (Full Name) *Parent/Legal Guardian *Email *Date *Physician InformationName of Physician *Doctor's License Number *Office Phone *Address: City, State and Zip *In case of an emergency, please contact:Name of Caregiver or family member *Address: City, State and Zip *Home PhoneWork PhoneCell Phone *Submit Other Adult Services Employment Services Community-Based Day Programs Tailored Day Services Independent Living Skills The Jarrett Family Computer & Media Arts Program Stroke and Brain Injury Services Phil Egan Program for the Arts