Medical Release Form For Minors Attending With A Guardian (Page 2 of 2) in pdf

Medical Release Form For Minors Attending With A Guardian Page 2

Name of Minor Child: _______________________________ Age: _________ Date of Birth: _______________

Date of Minor's Last Tetanus Shot (if known):

Do you have a medic alert tag, and for what condition:

_____________________________________

__________________________________________

Known Allergies (food, insects, medication, others):

________________________________________________________________________________________

___________________________________________________________________________________________

Do you carry medication for your allergies (If yes, list medications and dosages):

________________________________________________________________________________________

Current medications (include herbal, and over the counter, as well as prescription medications, including birth control

pills):

___________________________________________________________________________________________

Medical history (including medical conditions or other important fact that should be known):

________________________________________________________________________________________

___________________________________________________________________________________________

Special beliefs (any religious or other beliefs that might have an effect on medical care, such as blood transfusions,

etc.)

________________________________________________________________________________________

___________________________________________________________________________________________

Medical Release Form For Minors Attending With A Guardian Page 2