Medical Release Form (Child) printable pdf download

MEDICAL RELEASE FORM (Child)

Name:__________________________________________________Date of Birth__________

Address:_____________________________________________________________________

______________________________________________________________________

Parent/Guardian:______________________________________________________________

Phone: (H)________________(W)__________(C)___________

Height:_______________Weight:________________ Date of last tetanus shot:_____________

Primary Care Physician:__________________________Phone Number:__________________

Emergency Contact Name/Phone Number:__________________________________________

Medications: (Please list names, dosages, side effects and who prescribes them. Please also

make note if medication impacts balance, sensitivity to sunlight, etc)______________________

____________________________________________________________________________

Please check any areas of medical concern. Please explain in the comments section.

Areas

Comments

Auditory_____________________________________________________________________

Visual_______________________________________________________________________

Speech______________________________________________________________________

Cardiac______________________________________________________________________

Circulatory___________________________________________________________________

Pulmonary___________________________________________________________________

Neurological (seizure disorder?)___________________________________________________

Muscular_____________________________________________________________________

Orthopedic___________________________________________________________________

Allergies/Asthma_______________________________________________________________

Allergy to hay_______ Bee Stings________ Dust_________ Mold________

Does your child carry an Epi Pen or inhaler?___________________________________

Medical Release Form (Child)