Medical Authorization Form

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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 #_____________________________

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