Medical Release Form

  • In the event of sickness, accident, or injury, I give permission for my daughter to have administered to her whatever emergency treatment is deemed necessary by the attending doctor/nurse/medical technician.
  • My daughter has the following medical conditions or allergies, which should be noted in case of sickness, accident, or injury. (e.g., asthmatic, diabetic, allergies to specific drugs, hyper reaction to bee stings, bleeds easily, etc.). Please state “NONE” if there are no known problems or conditions.
  • (Please provide your family's insurance information)
  • (Please provide your family's policy number and group number)
  • By placing your name in the box below, you are indicating that all information provided is the most accurate and up-to-date information about your child.
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