Docstoc

Medical Release Form For Parents

Document Sample
Medical Release Form For Parents Powered By Docstoc
					                                   MEDICAL RELEASE FORM and EMERGENCY CONTACT INFORMATION

                                 Parents are responsible for keeping this information current
         PRINT
This is to certify that my child                          has my permission to participate in the Longfellow School after
school program. I authorize representatives of Longfellow Elementary School to seek appropriate medical action on my
behalf for emergency treatment of my child.

Child's Name                                               Date of Birth

Street Address

City, State and Zip Code

Parent's Name                                       Work Phone                      Home Phone

                                                    Cell Number                     Pager

Parent’s Name                                       Work Phone                      Home Phone

                                                    Cell Number                     Pager

Emergency Contact                                   Work Phone                      Home Phone

                                                    Cell Number                     Pager

Known allergies (including medication)

My child has the following medical problem(s), which should be noted



Physician or Clinic                                                        Phone Number

Hospital Choice from Insurance Plan

Insurance Carrier

Policy Number                                                      Phone Number

PERSONS AUTHORIZED TO PICK UP CHILD, OTHER THAN PARENTS
Name                                 Relationship     Telephone Number




OTHER INFORMATION
Please provide any other information, which you believe, will be helpful in understanding and caring for your child.




PARENT/GUARDIAN SIGNATURE
A parent/guardian signature is required, indicating acceptance of the policies stated in the registration packet.


              Parent/Guardian's Signature                                  Parent/Guardian's Signature
              \

              Parent/Guardian's Printed Name                                        Parent/Guardian's Printed Name


                            Date                                                            Date
2002 Extended Day/Medical Form
NOTARY SEAL

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:27
posted:6/10/2009
language:English
pages:2