Student Health And Emergency Release Form

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Classes My Child is enrolled in:
BELMONT PUBLIC SCHOOLS
PLEASE FILL OUT ONE
Session 1: _______________________
FORM PER CHILD
Session 2: _______________________
Session 3: _______________________
Student Health and Emergency Release Form
Student’s Name: ____________________________________
Birth Date: _______________________
Street Address: _____________________________City____________________State MA Zip_________
EMERGENCY CONTACT INFORMATION
Parent/ Guardian Name(s):
Name: _________________________ Home Phone (_____) ______________Mobile Phone (_____)____________
Name: _________________________ Home Phone (_____)______________Mobile Phone (______)___________
In an emergency, when parent/guardian cannot be reached, please contact the following:
Name: _________________________Home Phone (______)______________Mobile Phone (_____)____________
Name: _________________________Home Phone (______)______________Mobile Phone (_____)____________
Who can pick your child up?
1.
___________________________________________________________________________________
2.
___________________________________________________________________________________
Please list any known Allergies and describe the reaction that occurs:
PLEASE NOTE: YOUR CHILD MUST HAVE HIS / HER EPIPEN AT CAMP
Other Medical Conditions:
________________________________________________________________________
Student’s Physician: __________________________________ Phone: ___________________________________
Health Insurance Company: _______________________________Policy Number: ___________________________
AUTHORIZATION FOR TREATMENT OF MINOR
In the event of an emergency, I hereby give permission to secure proper treatment for my child. If necessary, this
includes selection of physicians and medical treatment facilities that are then authorized to perform such medical
treatments as deemed necessary to protect the health of my child.
___________________________________
_________________________________________________
Date:
Signature of Parent/Guardian Required
THIS FORM SHOULD BE COMPLETED AND RETURNED TO KATIE KELLEY IN THE SUMMER ENRICHMENT OFFICE

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