Medical Permission Form For School printable pdf download

Medical Permission Form

Trinity Lutheran School, 250 South Indiana Avenue, Crown Point, Indiana

Basic Information

(Please print)

Name: ____________________________________________________

Age: _______ Gender: _______

Last

First

Middle

Address: ______________________________________________________________________________

Street

City

State

Zip

Date of Birth: __________________________

Home Phone: __________________________

Father/Guardian Name: ______________________ Cell: __________________ Work: __________________

Mother/Guardian Name: _____________________ Cell: __________________ Work: __________________

Alt. Emergency Contact: _____________________ Cell: __________________ Home: _________________

Student’s School:

Trinity Lutheran School

School Secretary: Lisa Ann Cizmar

250 S. Indiana Ave

School: 219-663-1586

Crown Point, IN 46307

Brief Medical History

Special Health Condition (list)

Medication and Dosage (if taken)

1. _____________________________________________________________________________________

2. _____________________________________________________________________________________

3. _____________________________________________________________________________________

Additional related information: _______________________________________________________________

Should student be restricted from any type of activity? No Yes, Explain: _____________________________

Is student allergic to any medication? No Yes, List: ______________________________________________

Authorization for Treatment

I, the parent or legal guardian of (child) ________________________, authorize ________________________

to obtain medical care for my child in the event such care is necessary. I understand that, if possible, I will be

contacted in the event my child requires medical attention. I grant to a licensed health care provider or

accredited hospital permission to perform any medical and/or surgical procedures that are essential for the

treatment of my child and agree to be responsible for payment for such care.

I release Trinity Lutheran School, Crown Point, IN, its employees and agents, from any damages, liability, or

loss resulting from their securing in good faith medical care for my child.

Parent/Guardian Signature: ____________________________________ Date: ______________________

Medical Permission Form For School