Medical Release Form For Minors Parent Guardian Consent (Page 2 of 3) in pdf

Medical Release Form For Minors Parent Guardian Consent Page 2

[ ] Dizziness

[ ] Heart Trouble

[ ] Kidney Trouble

[ ] Sinusitis

[ ] Seizures

[ ] Stomach Upset

[ ] Other (Explain below)

__________________________________________________________________________________

Immunizations:

[ ] Tetanus: Date Received ____________________

Medications: List any prescription drugs the student will be taking while on trip (include fre-

quency and dosage for each).

__________________________________________________________________

_________________________________________________________________________________

Comments: _______________________________________________________________________

_________________________________________________________________________________

EMERGENCY NOTIFICATION

Parent/Guardian ____________________________________________________________________

Address ____________________________________________ Phone _______________________

Relationship _________________________________________

NOTARY

Dated this _______ day of ____________________, 20_____. State of ______________________.

On this _______ day of ____________________ ,20_____, (parent/guardian) personally appeared

before me, and in my presence executed the within and foregoing permission and release form.

Witness my hand and official seal this _______ day of ____________________, 20_____.

My commission expires ________________________

Signature Notary Public ______________________________________________________________

Medical Release Form For Minors Parent Guardian Consent Page 2