Medical Release Form

First Name

Last Name

Gender

Birth Date

First Name

Last Name

Home Phone

Work Phone

Email

Street Address

Street Address Line 2

City/Suburb

State/Province

Postal/Zip Code

Does your child have any allergies?

List all allergies your child has been diagnosed with.

Does your child have any medical problems?

Detail any current or past medical conditions your child has experienced.

List all medications your child is currently prescribed, including the name of the medication, dosage, and administration route.

Insurance Company

Policy Number

Family Doctor's Name

Family Doctor’s Phone Number

I certify that the information submitted by me in this application is true and correct to the best of my knowledge.

Parent / Guardian Signature