Medical Information Form

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MEDICAL INFORMATION
AUTHORIZATION FOR MEDICAL TREATMENT
Year of 2016
MEDICAL/EMERGENCY INFORMATION
Student Name: _________________________________________Date______________________________
Email:_________________________________________________________________________________
Birth Date: ___________________
Last Tetanus Immunization:____________________
Medical Allergies/ Significant Medical History:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
___________________________________________________________
Mother’s Name: ___________________________ Home #: ______________ Cell #: ________________
Father’s Name: ____________________________ Home #: ______________ Cell #: ________________
Name of Physician: _______________________________ Phone #: ______________________
Address: _____________________________________________________________________________
Medical Insurance Company: ____________________________________________________________
Insurance Number: __________________________________________
Other Contact in Case of Emergency:
Name: ___________________________________ Phone #: _____________________________
Relationship: ________________________________________
MEDICAL RELEASE
In the event that the undersigned, or my (our) authorized physician, cannot be reached and in the judgment of
Tracey Rapp or other appropriate staff member, there is a necessity for immediate examination and/or treatment of my
(our) child, I (we) hereby request and authorize any of the aforesaid personnel to obtain for my (our) child such medical
services as are deemed necessary. I agree to assume the financial responsibility for any diagnosis/treatment and for
medication deemed necessary.
_______________________________________________
Parent/Guardian Signature
____________________
Date
_______________________________________________
Parent/Guardian Signature
____________________
Date