Emergency Medical Release Form

The following information is necessary to provide appropriate medical service, if required.

Student Information

Personal Medical History

If your child has (or had) any of the following conditions, please select

Disabilities

Allergies

Does your child have any allergies? *

Medications

Is your child taking any medications or currently receiving other medical treatment? *

In Case of Emergency

Mother’s or Guardian’s Information

Father’s or Guardian’s Information

Relative or Designated Adult who can be reached in the event that parents or guardians are unavailable

Does this person have permission to pick your child up?
SIGNATURE OF PARENT/GUARDIAN *
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