Medical Release Form

Child Information

First Name

Last Name


Gender

Birth Date

Parent/Guardian Information

First Name

Last Name


Home Phone

Work Phone


Email


Street Address

Street Address Line 2


City/Suburb

State/Province

Postal/Zip Code

Medical Information

Does your child have any allergies?

Does your child have any medical problems?

Insurance Company

Policy Number


Family Doctor's Name

Family Doctor’s Phone Number

Medical Information

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

Parent / Guardian Signature 

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