Kids Medical Release Form

Medical Release Form

First Name

Last Name

Phone Number

Name of Family Doctor

Insurance Carrier

Policy or Group Number

Insurance Phone Number

Are there any current health issues? Especially those that we would know in case of an emergency.

Known Allergies

Current Medications

Please send all medication in original bottles or packaging with specific instructions as to correct dosing for your student. No loose pills in baggies or envelopes.

Signature

Date Input