Medical Release and Permission Form

Todays Date

First Name

Last Name

Phone Number

Email Address

Year in School

Medical Insurance Company

Insurance Policy Number

Physician Name

Physician Office Phone #

Dentist Name

Dentist Office Phone #

Parent/Guardian 1 Name

Parent/Guardian 1 Phone #

Parent/Guardian 2 Name

Parent/Guardian 2 Phone #

Other Emergency Contact Name

Other Emergency Contact Phone #

List Allergies

Date of last tetanus

Eyewear (glasses or contacts)?

Detailed information regarding any conditions or required actions

Additional Notes (office only)

Major illnesses in the past year

Student Acceptance of Conduct Agreement Signature

Date of Signature

Administrative notes student conduct

Parent/Guardian Signature

Date of Signature

Thank you for your submission, we will be in touch!