Please print out this page and give a sign copy to your child's chaperone.

Medical Release Form

Parent/Guardian Name:

I hereby give permission for any and all medical attention to be administered to

Child's Name:
Age :

in the event of accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment.

Dates Effective :
Address :
Home Phone :
Cell Phone :
Insurance Comp :
Policy #:

In case I cannot be reached, any of the following persons is designated to act on my behalf.

Adult in charge of trip :
Phone Number :
Emergency Contact :
Phone Number :
Other :
Phone Number :

Medical Information

Medications :
List any information that would be helpful should we need to seek medical assistance :
Known Allergies :
Describe your reaction :
What protocol is to be followed if you come in contact with an allergen :
Physician :
Phone Number :

Signature (Parent/Guardian):

Date: