MEDICAL RELEASE FORM

MINOR CHILD

EFFECTIVE FOR ALL TRIPS AND/OR FUNCTIONS WITH GALAX CHRISTIAN SCHOOL FOR THE SCHOOL YEAR 2023-2024

 

Name of student:  _________________________________________________________________________________

 

Address:  ____________________________________Birthdate:______________________________________________

 

Phone number ________________________________   Parent/Guardian Name _________________________________

Medical Information

Physician’s Name and Telephone #

Drug Allergies/Allergies

Current Medications

 

 

 

 

 

 

 

 

 

List all pertinent medical problems:

I give permission to dispense over the counter medications to my child          _______ Yes                ________ No

 

IN CASE OF  EMERGENCY, CONTACT:

Name :   ____________________________________________ Cell Phone _____________________________________

Home Phone:  _______________________________________ Work Phone ____________________________________

 

2nd Contact: 

Name :   ____________________________________________ Cell Phone _____________________________________

Home Phone:  _______________________________________ Work Phone ____________________________________

MEDICAL INSURANCE INFORMATION

Policy Holder ____________________________________________Group # Policy Number _______________________

Insurance Company _______________________________________

Insurance Phone Number ________________________________________________________

MEDICAL RELEASE:

I understand that in the event medical treatment is required for the above-named minor, that every effort will be made to contact me.  However, if I cannot be reached, I give my permission to the staff of Galax Christian School to secure the services of a licensed physician to provide the care necessary, including anesthesia, for my child’s well-being.

Signed:  ________________________________  (Parent or Guardian)   Date:__________________