Preschool Medical Release Form

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Preschool Medical Release Form
School Year: ____________
Student’s Name: __________________________________________________________ Grade: _____________
Father’s Name: __________________________________ Mother’s Name: ________________________________
Address: ____________________________________________________________________________________
Home Phone: _________________Father’s Cell: _________________ Mother’s Cell : _______________________
Student lives with?  Both Parents  Mother  Father  Guardian  Foster Home
Please number in order of preference your desired procedure in the case of illness or injury:
( ) Contact Father’s Employer: ______________________________________ Phone: _____________________
( ) Contact Mother’s Employer: _____________________________________ Phone: _____________________
( ) Emergency Contact Person: _____________________________________ Phone: ______________________
( ) Emergency Contact Person: _____________________________________ Phone: ______________________
* One of the above must be available to pick up the child if he/she has to go home.
Family Doctor: _________________________________________ Phone: ________________________________
Family Dentist: _________________________________________ Phone: ________________________________
Does this child have food allergies?  No  Yes
If yes, please specify: ___________________________________ Type of reaction: ________________________
Does this child have drug allergies?  No  Yes
If yes, please specify: ___________________________________ Type of reaction: ________________________
Is an Epi-pen required/prescribed by a doctor?  No  Yes
Does your child carry an Epi-pen with him/her?  No  Yes If yes, Doctor’s Order (school form) is needed. Parent
is responsible for providing the Epi-pen.
Does this child have asthma?  No  Yes If yes, list triggers/symptoms: ________________________________
Has your doctor prescribed an inhaler?  No  Yes If yes, list name of inhaler: __________________________
If yes, Doctor’s Order (school form) is needed. Parent is responsible for providing medication to the school.
Does this child have chronic or medical conditions/illnesses? If yes, check:  Seizures  Diabetes ( Type 1 or
 Type 2)  Cardiac Condition  Other, specify ____________________________________________________
Please list any other important information to help us better care for your child while at school: _______________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Please list medications & reason for taking at home: _________________________________________________
Please list medications & reason for taking at school: _________________________________________________
* All prescription medications that need to be given during school hours must have a Doctor’s Order (school form)
and be kept in the nurses’ office.
(Over)

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