Grandstreet Medical Release Form
Please complete this form for each enrolled student.
Emergency Contact Information
Student Name *
Age *
Name of Parent/Guardian 1 *
Parent/Guardian 1 Relationship *
Required
Parent/Guardian 1 Home or Cell Phone *
Parent/Guardian 1 Work Phone
Name of Parent/Guardian 2
Parent/Guardian 2 Relationship
Parent/Guardian 2 Home or Cell Phone
Parent/Guardian 2 Work Phone
Release
Parent’s or Guardian’s Electronic Signature *
By typing my name, I authorize Grandstreet Theatre School and its representatives to secure medical attention and care in the event of illness or accident for the above named child. In case of emergency, I understand that Grandstreet staff will contact me as soon as possible. Permission is also granted to the doctor or the hospital and their associates to perform the necessary medical and surgical procedures necessary for the child.
Medical Information
Physician Name and Phone
Current Medication (if any)
Known Allergies
Diabetes
Please indicate treatment plan and relevant medications.
Other Medical Concerns
Is there any information that might help us more effectively meet the needs of your child?
(i.e. learning styles, reading skills, attention span, etc)
Submit
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