Child Medical Release Form printable pdf download

Child Medical Release Form

Student Name: ____________________________________________________ Birthdate: ___________________

Address: ______________________________________________________________________________________

City: ___________________________________ State: __________ Zip: _______________________

Home Phone: ____________________________________________

Parent’s Email: ___________________________________________

Student’s Physician: _________________________

Physician’s Phone Number: ____________________________

Name of Insurance Company: _____________________________________________________________________

Policy Number: _____________________________________

Group Number: ____________________________

Date of last Tetanus Shot: _____________________________

List allergies and medications (and dosage) your child has or is taking; or any other medical information a doctor should be

aware of:

______________________________________________________________________________________________

OVER-THE-COUNTER MEDICATION RELEASE

By indicating “Y” beside the listed over-the-counter medications and signing below, I authorize a representative of First

Baptist Church and/or medical professionals to administer said medication in accordance with label instructions if

requested by my child.

Advil _____

Tylenol _____

Benadryl _____ NyQuil/DayQuil _____

Tums _____

Pepto Bismol _____

Imodium AD _____

Dramamine _____

Tetanus Shot _____

Prescription Meds sent w/Student _______

(See Other Side)

Child Medical Release Form