Archway
C lassical
A cademy
-‐
T rivium
Accident
W aiver,
R elease
o f
L iability,
a nd
Medical
A uthorization
F orm
SECTION 1 – GENERAL INFORMATION
FAMILY LAST NAME ______________________________________ DATE __________________
PARENT’S NAME _______________________________ PARENT’S NAME ___________________________
STUDENT’S NAME ____________________________ DATE OF BIRTH ____/____/_____ GRADE _______
MEDICAL CONDITIONS, ALLERGIES _________________________________________________________
PRESCRIPTION MEDICATIONS _______________________________________________________________
STUDENT’S NAME ____________________________ DATE OF BIRTH ____/____/_____ GRADE _______
MEDICAL CONDITIONS, ALLERGIES _________________________________________________________
PRESCRIPTION MEDICATIONS _______________________________________________________________
STUDENT’S NAME ____________________________ DATE OF BIRTH ____/____/_____ GRADE _______
MEDICAL CONDITIONS, ALLERGIES _________________________________________________________
PRESCRIPTION MEDICATIONS _______________________________________________________________
STUDENT’S NAME ____________________________ DATE OF BIRTH ____/____/_____ GRADE _______
MEDICAL CONDITIONS, ALLERGIES _________________________________________________________
PRESCRIPTION MEDICATIONS _______________________________________________________________
EMERGENCY CONTACT NUMBER 1 ____________________________ 2 _____________________________
ADDRESS ___________________________________________________________________________________
PHYSICIAN _______________________________________ OFFICE NUMBER _________________________
PRIMARY INSURANCE _______________________________________________________________________
POLICY HOLDER’S NAME ____________________________________________________________________
RELATIONSHIP TO STUDENT _________________________________________________________________
ID # ___________________________________________ GROUP/POLICY #_____________________________