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Emergency Medical Release Form
The following information is necessary to provide appropriate medical service, if required.
Student Information
First Name
*
Middle Name
Last Name
*
Date of Birth (MM/DD/YYYY)
*
Gender
*
Age
*
School
*
Parent/Guardian Home Address
*
Address 2
City
*
State
*
Ohio
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
ZIP Code
*
Phone
*
Personal Medical History
If your child has (or had) any of the following conditions, please select
Alcohol/Drug Abuse
Asthma
Diabetes
Eating Disorders
Emotional Problems
Hay Fever
Heart Disease
Hepatitis
High Blood Pressure
Kidney Disease
Migraine Headache
Pneumonia
Rheumatic Fever
Seizures
Thyroid Trouble
Tuberculosis
Ulcers
Please list any surgeries your child has had
Date of Last Tetanus Shot (MM/DD/YYYY)
List any other pertinent medical information
Disabilities
My child needs accommodation for the following physical limitation(s) and/or handicap(s)
Allergies
Does your child have any allergies?
*
Yes
No
If yes, please specify
Specify any dietary issues
Medications
Is your child taking any medications or currently receiving other medical treatment?
*
Yes
No
If yes, please specify
In Case of Emergency
Mother’s or Guardian’s Information
Name
Home Telephone
Work Telephone
Place of Work
Father’s or Guardian’s Information
Name
Home Telephone
Work Telephone
Place of Work
Relative or Designated Adult who can be reached in the event that parents or guardians are unavailable
Name
Phone
Does this person have permission to pick your child up?
Yes
No
SIGNATURE OF PARENT/GUARDIAN
*
clear
RELATIONSHIP TO CHILD
*
DATE (MM/DD/YYYY)
*