Medical Information & Release Form


Entering grade ____________ in August 20_______
Please PRINT!!
Male £
Female £
STUDENT’S NAME__________________________________________ DATE OF BIRTH_________________
Home Address________________________________________________ City__________________ Zip_________
Home Phone Number ____________________________________________________________________________
Parent or Guardian Name(s) _______________________________________________________________________
Mother’s Employer____________________________________________________________________________
Mother’s Work Number_____________________________ Mother’s Mobile____________________________
Mother’s Email Address________________________________________________________________________
Father’s Employer____________________________________________________________________________
Father’s Work Number_____________________________ Father’s Mobile_____________________________
Father’s Email Address________________________________________________________________________
PHYSICIAN___________________________________________ Phone Number___________________________
In the event of an emergency, please list two people whom we may contact if we are unable to reach the parents.
Relationship to Student__________________________________ Mobile Phone Number_________________
Relationship to Student__________________________________ Mobile Phone Number_________________
INSURANCE COMPANY_______________________________________ Policy Number___________________
ALLERGIES (food, medications, etc.)______________________________________________________________
MEDICATIONS (taken regularly)_________________________________________________________________
DIETARY RESTRICTIONS_____________________________________________________________________
OTHER Does your child have any medical history, current health problems, or recent medical/surgical treatment we
should know about?______________________________________________________________________________
The Georgia Certificate of Immunization is required by law for all students. Your GA Form 3231 must be on
file in the Stratford Academy Registrar’s Office. Date of Last Tetanus Injection:_________________________
In the event that he/she is injured while attending a school-sponsored trip and requires the attention of a doctor, we
consent to any reasonable medical treatment as deemed necessary by a licensed physician. In the event treatment is called for which a
physician and/or hospital personnel refuse to administer without our consent, we hereby authorize Sue Appleby, Margaret Brogdon, Kelly
Causey, Mark Farriba, Redonda Mann, Robert Veto, or assigned school representative to give such consent for us if we cannot be reached by
telephone at one of the numbers indicated above. In the event it becomes necessary for any of these persons to give consent for us, we agree to
hold such persons, the school, and any of its representatives, staff or officers, free and harmless of any claims, demands, or suits for damages
arising from the giving of such consent so long as the treatment is administered by or under the supervision of a licensed physician.
Mother’s Signature____________________________________________________ Date______________________
Father’s Signature_____________________________________________________ Date______________________
Student’s Signature____________________________________________________ Date______________________
(Middle & Upper School Students only)
Stratford Academy must have a completed MEDICAL INFORMATION & RELEASE FORM for each student.
This completed form must be returned to the student’s homeroom teacher/advisor the first week of school.
Revised May 2016


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