Medical Release Form

Student's Name*
First Last
Gender*
- Male
- Female
Date of Birth: (mm/dd/yyyy)*
MM slash DD slash YYYY
Grade in 2017:*
Please enter a number from 1 to 12.
Age:*
Please enter a number from 5 to 29.
Student's Street Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent's Name:*
First Last
Emergency Contact:*
First Last
Emergency Contact Phone:*
Other Phone:*
Insurance Company:*
Policy Number of Student:*
All Known Allergies: (Food, medicine, etc.)*
Health Information/Current Medications we should know about: