Medical Release
Name of Student: _________________________________________ Date of Birth:_________________
Address:____________________________________________________________________________________
______________________________________________________
Home phone #:______________________
Participant�s Social Security Number: ________________________ (Required for treatment in most Hospitals.)
Emergency Medical Treatment: In the event of an emergency, I hereby give permission to transport my child to a hospital for emergency medical attention. I wish to be advised prior to any further treatment by the doctor and hospital. If you are unable to reach me, contact:
Emergency contact __________________________________ Phone # ____________________________
Relation to participant _________________________________
If you are unable to reach parent/guardian or the emergency contact person, I hereby grant permission for the doctor and hospital to exercise professional judgment in treating participant.
Medical / Hospital Insurance Carrier ______________________________________________________________
Name of Policy Holder ________________________________
Relation to participant _____________________
Policy Number ______________________________
Group Number __________________________________
Signature of Parent / Guardian _____________________________________
Date ______________________
Father/Guardians full name:__________________________________________________________________
Social Security Number: __________________________________________ Phone #:___________________
Home address:_______________________________________________________________________________
Place of business/address:_____________________________________________________________________
_______________________________________________________________ Phone #: ___________________
Mother/Guardians full name:_________________________________________________________________
Social Security Number: __________________________________________ Phone #:___________________
Home address:_______________________________________________________________________________
Place of business/address:_____________________________________________________________________
_______________________________________________________________ Phone #:____________________
(Both sides need to be complete and signed)
Name of Participant ___________________________________________
Medications: My child is taking the following medication(s):
Description _______________________________________ Dosage ________________________
Description _______________________________________ Dosage ________________________
(EITHER A PHYSICIANS PRESCRIPTION OR PARENT NOTE MUST ACCOMPANY ALL MEDICATIONS. PRESCRIPTION / NOTE SHOULD BE ATTACHED TO THIS FORM.)
I hereby grant permission for non-prescription medications to be given, if deemed appropriate.
Drug allergies ________________________________________________________________________
____________________________________________________________________________________
Other allergies / reactions (food, plants, insects, etc.) _________________________________________
____________________________________________________________________________________
List any other health problems / limitations that we need to be aware of ___________________________
_____________________________________________________________________________________
Signature of Parent / Guardian ______________________________ Date ______________________