Medical Release Form printable pdf download

Medical Release Form

MEDICAL RELEASE FORM

Parent/Legal Guardian’s Name: _________________________________________________________________

Address: __________________________________________________________________________

Phone #s: Home (____) ________________________

Work (____) ________________________

Cell (____) ________________________

Other (____) ________________________

List all Known Medical Conditions, Including Food Allergies and/or

CHILDREN’S INFO

Drug Allergies. In Addition, Include Any and All Over-the- Counter and/

or Prescription Drugs Taken Regularly.

Child 1 Name ________________________________ _______________________________________________

_______________________________________________

Child 2 Name ________________________________ _______________________________________________

_______________________________________________

Child 3 Name ________________________________ _______________________________________________

_______________________________________________

Child 4 Name ________________________________ _______________________________________________

_______________________________________________

In an emergency, please contact: _______________________________________________

Relationship to child/children: _______________________________________________

Phone #s: (____) ________________________ (____) ________________________

(____) ________________________ (____) ________________________

MEDICAL RELEASE FORM

Medical Release Form