Medical Information/Emergency Release Form
A form must be completed,signed, and submitted to UFCA by the first day of school each school year for all students. Registration is incomplete without this form on file in the Academy Office.

PLEASE HAVE ALL DOCUMENTS AVAILABLE WHEN FILLING OUT THIS FORM. YOU CANNOT SAVE AND COME BACK.

You will need your Insurance Card, Doctor phone number and address, Emergency contact information.

If your child takes medication or has allergies you will need to print out a Medical Release Form and Allergy Action Plan and fill it out by hand. Your child's doctor will need to sign the form.

Student Name *
Your answer
Entering Grade *
Your answer
Cell Number
Your answer
Date of Birth *
Your answer
Gender *
Required
Mother
Your answer
Mother's Cell Number
Your answer
Father
Your answer
Father's Cell Number
Your answer
Address *
Your answer
Primary Physician *
Name
Your answer
Primary Physician Address
Your answer
Primary Physician Phone
Your answer
Allergies and Medical Issues
For the following questions you may also need to fill out an Allergy Action Plan and/or a Medication Release Form. You can request both forms from the Academy Office or you can print them out from the school website ufca.org.

They will need to be signed by your Physician.

Please list any known allergies.
You will need to pick up an Allergy Action Plan form in the Academy Office if allergies are listed
Your answer
Please list any non allergy issues that the school should know about.
Surgeries, current injuries, current medical issues like Diabetes, ADHD, etc.
Your answer
Emergency Contacts
In case of accident or serious illness, UFCA will contact the parent/guardian. If the school is unable to contact the parent/guardian/above designated person, the school will make necessary arrangements for immediate treatment. Payment of any fees will be assumed by the parent/guardian. I hereby give my consent to any hospital/licensed physician/authorized provider to administer necessary emergency treatment to my child in the event such treatment is imperative and I cannot be contacted.
Emergency Contact Name *
Your answer
Emergency Contact Number *
Your answer
Relation to student *
Your answer
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