Peace Lutheran Church Medical Release and Permission Form
Name
Your answer
Birthdate
MM
/
DD
/
YYYY
Address
Your answer
Phone: (home)
Your answer
Parent Cell
Your answer
Email
Your answer
Year in School
Your answer
Gender
Mother’s Name
Your answer
Mother’s Work Phone
Your answer
Father’s Name
Your answer
Father’s Work Phone
Your answer
Emergency Contact
(if parents cannot be reached)
Your answer
Emergency Contact's Phone
Your answer
Medical Insurance Co.
Your answer
Doctor/Clinic
Your answer
Doctor/Clinic Phone
Your answer
Dentist
Your answer
Dentist's Phone
Your answer
Please check the following areas :
For your child’s safety and for our knowledge, is your child a :
Required
Does your child have allergies?
Your answer
Does your child have or is he/she being treated for any of the following?:
Required
Please list and explain any major illnesses your child experienced during the last year:
Your answer
Does your child wear:
Required
Date of last tetanus shot:
MM
/
DD
/
YYYY
Medications/Dosage (if any):
Your answer
Note: if necessary, describe in detail the nature and severity of any physical and or psychological ailment, illness, limitation, handicap, disability or condition to which your child is subject that the staff should be aware of. Submit this notification in writing and attach it to this form.
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