Cumyf Medical Release Form 2015 Page 2
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1
2HEALTH HISTORY
Name ________________________________
(
Please complete both sides)
Medical Conditions
Allergies
______________________________
__________________________
______________________________
__________________________
______________________________
__________________________
______________________________
__________________________
Date of Last Tetanus booster _____________________
Medication Taken (please list) _______________________________________________
_________________________ is parent sending it? ( ) yes ( ) no
(Please send in original containers)
Please initial any of these non-prescription meds which your child may be given to ease
minor discomforts.
Tylenol: ___ Motrin ___ Benadryl: ___ Dramamine: ___ Pepto-Bismol: ___ Imodium: __ Tums: __
Other Considerations: _____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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