Medical-Release Form
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1
2United Church of Christ
Massachusetts Conference
Medical-Release Form
(Each Child Needs a Separate Form)
PLEASE RETURN COMPLETED FORM TO:
MACUCC, Attn: Andrea Bellarosa, One Badger Road, Framingham, MA 01702
Please clearly print all information
Name of Child__________________________________________________________________
First
Nickname
Middle Initial
Last
Date of birth ____/ ____/ ___
Current Grade____________________________
Address_______________________________________________________________________
Name of parent/guardian attending Super Saturday__________________________________
Cell Phone #_____________________
Child’s physician_________________________
Phone___________________________
Other Emergency contact_________________________________
Cell Phone #
Relation to child________________________________
Health history (please check all that apply)
Frequent colds
Seizure disorders
Physical disability
Appliances (retainers
Stomach upsets
Diabetes
Mental disability
contact lenses, etc.)
Asthma
Vision/hearing
Emotional/behavioral
Sleep disturbances
Impairment
disability
Motion sickness
Other
_____________________________________________________________________________
Allergies___________________________________________________________________
If any of the above is checked, please give important details_____________________________
_____________________________________________________________________________
Date of last Tetanus shot:
Medications
Is your son/daughter taking a prescription or non-prescription medication?
yes
no
If yes, please answer the following:
1.
Medication________________________________________________________
Dosage and Frequency of dosage____________________________________________
2.
Medication________________________________________________________
Dosage and Frequency of dosage____________________________________________
3.
Medication________________________________________________________
Dosage and Frequency of dosage____________________________________________
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