School:____________________________

Emergency Medical Release

 

Name

---

                              

Address

---

                               

Phone (______)__________________

 

Father's Place of Employment		Phone(       )         -
Address
Mother's Place of Employment		Phone(       )         -
Address

 

Enrolled Children and Siblings:

First Name (and last name, if different)	Does child have any serious health problems? (If yes, please identify)

 

Emergency Contacts  (at least two besides parents):
Name/Address/Telephone

 

---

---

 

May we administer regular first aid including ambulance if deemed appropriate?      Yes_______  No________

 

Do you authorize hospital or doctor to administer necessary medical treatment?       Yes_______  No________

 

______________________ does not pay physician fees or medical expenses of students who are injured at school or school-sponsored activities.

 

 

Authorized Signature__________________________________________Date___________________

                                                   (Parent or legal guardian)

 

Insurance Information:

Please attach name of company, policy number, membership, etc. or a photocopy of insurance card(s).