MEDICAL RELEASE FORM

Downloadable paper copy: click here

Student's Name: *
Student's Name:
Date of Birth:
Date of Birth:
Address:
Address:
Address (if different from child):
Address (if different from child):
Please list the child's allergies (please check all that apply):
Does your child have any life-threatening allergies?
Is your child bringing any medication with him/her?
PLEASE NOTE: Medication should be in its original prescription bottle/package, which should have administration instructions and the child’s name clearly indicated.
Does your child have any physical, emotional, mental or behavior concerns or limitations that our staff should be aware of?
Has your child had any of the following:
Date of Last Tetanus Shot:
Date of Last Tetanus Shot:
In the case of a medical emergency, I understand that hospital policy requires parental permission before treatment. I hereby give my permission to a representative of the Evangelical Free Church of Redwood Falls to administer medication as identified above and to secure proper medical treatment: Parents will be notified immediately of any medical emergency.
Date:
Date:
Emergency Contact (in event parent/guardian cannot be reached:)
Emergency Contact (in event parent/guardian cannot be reached:)
Emergency Contact Phone:
Emergency Contact Phone: