Consent Form Release From Liability And Indemnity (Page 2 of 2) in pdf

Consent Form Release From Liability And Indemnity Page 2

MEDICAL INFORMATION FORM

Student’s Name __________________________________________________________ ___

Parent/Guardian’s Name ________________________________ _____________________

Home Address ________________________________________________________ _____

Home Phone __________________Cell Phone _______________Pager _________ _______

Medical Insurance Provider: _____________________________________________ ______

Medical Insurance Policy: _________________________________________________ ____

Policy #: ___________________________________________________________________

Primary Subscriber of Medical/Health Policy: ______________________________ _______

Name of Student’s Health Care Provider____________________ Phone # _______ ______

If parent/guardian not available in emergency, please notify:

Name _____________________________ Name ________________________ _________

Phone _____________________________ Phone _______________________ __________

Address ____________________________ Address __________________ _____________

Relationship ________________________ Relationship____________________ ________

Health History

Please list any and all chronic or recurring illnesses:

___________________________________________________________________________

Please list any and all medication that your child takes on a regular basis:

___________________________________________________________________

___

_________________________________________________________________

_____

Please list any and all allergies, or drug sensitivity and instructions pertaining to their

administration:

___________________________________________________________________________

Greg Maslowe, Farm Manager

Newton Community Farm

617-916-9655

Consent Form Release From Liability And Indemnity Page 2