Medical Release Form

Please fill out the information below and submit.

I hereby give consent for a qualified physician or surgeon to examine, diagnose, prescribe, and perform treatment (including surgery) which is deemed advisable for the welfare of:
Student Name:*
First Last
I give permission for the above to take:*
- Tylenol (acetaminophen)
- Advil (ibuprofen)
- Imodium
- Benadryl
- Emetrol (nausea & vomiting)
- Dramamine
- Midol
- None
Note: Medications will not be given under any circumstances without prior written permission from parent /guardian. No student is permitted to have prescription or non-prescription on his/her person at any time.
Parent / Guardian Name:*
First Last
Signature*
Date*
MM slash DD slash YYYY
Medical History
Please list any medical concern and/or medications the student currently takes:
List Medical Allergies:
List Food Allergies:
List Environmental Allergies:
Date of last tetanus inoculation :
MM slash DD slash YYYY
Insurance Information
Insurance Company:
Policy Number
Subscriber Name:
First Last
Date of Birth:
MM slash DD slash YYYY
Subscriber Phone:
Student's Physician Name:
First Last
Physician's Phone:
PLEASE ATTACH A COPY OF YOUR INSURANCE CARD
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Medical Release form