Medical Release Form
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1MEDICAL
RELEASE
FORM
Doctor:___________________________
Address:___________________________________________________________
City,
State,
Zip
Code:_________________________________________________
Phone
Number:_____________________________________________________
Fax
Number:_______________________________________________________
To
Whom
It
May
Concern:
I
request
that
the
following
medical
records
be
forwarded
to
the
Washington
University
Family
Learning
Center.
These
documents
are
required
by
Missouri
State
Child
Care
Licensing
Standards
and
the
St.
Louis
City
Department
of
Health
in
order
for
my
child
to
attend
child
care.
Documents
required:
Physical
examination
form
with
statement
of
participation
(see
attached)
Current
immunizations
Lead
test
Other:_______________________________________________________
This
release
is
specific
to
the
documents
identified
above.
This
release
is
authorized
from
(date)__________________
to
(date)____________________________.
Please
send
these
documents
via
fax
to:
314‐935‐3272.
If
you
have
any
questions
or
need
any
additional
information,
please
contact
Julie
Grelle,
Assistant
Director,
at
314‐935‐5437.
Thank
you
for
your
assistance
in
this
matter.
____________________________________
__________________________
Parent/Guardian
Signature
Date
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Parent category: Legal