Medical Release Form
Name of Student:__________________________________ M F
Name of Parents _____________________________________
Address:____________________________________________________________________________
Phone number: ___________________________ Cell Phone # ________________________________
Emergency Phone # :_________________________ Emergency contact’s name_________________________
Student's birth date:_____________________
Student Health Concerns:
It is our commitment to do our best to protect and maintain your child/ren health. Please be detailed with the following questions. This will assist us in making the right decision in the least amount of time.
Allergies:_______________________________________________
Medications:____________________________________________
Conditions/Diseases that afflict him/her:
_____________________________________________________
Recommended procedures to handle health issues:
_______________________________________________________________________________
Pediatrician's Name, address, phone number:____________________________________________
______________________________________________
Hospital_______________________________________________
Alternate phone numbers or addresses where teacher or class coordinator can contact you or a responsible adult in case of
emergency:______________________________________
Is an older, responsible sibling on the premises during these classes? (circle one) YES NO
Name of older sibling _______________________________Class sibling is taking_________________________
Medical Release Agreement
Acting as the parent or legal guardian, I retain full liability for any physical injury to my child(ren) which occurs during the participation in any HEARTH event or activities during the 2007/2008 school year. I hereby give HEARTH permission to render such medical and hospital care as, in their judgment, may seem advisable for my child(ren) in the event of injury, illness or accident.
__________________________ _______________________________________
Date Parent/Guardian Signature