2022-2023
UNIVERSAL MEDICAL INFORMATION/EMERGENCY CONTACT
RELEASE AND CONSENT FORM
School
School Year
Name of Student (Last,First, Middle)
*
Grade
Teacher Name
Student Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Telephone
Please enter a valid phone number.
Preferred Email Address
example@example.com
Siblings at school
Name
Grade
Teacher
Name
Grade
Teacher
Name
Grade
Teacher
Is child living with both Parents/Guardians?
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Home Address (if different from child’s):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Home Phone (If different from child’s):
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Parent/Guardian Work Telephone
Please enter a valid phone number.
Parent/Guardian Mobile Phone
Please enter a valid phone number.
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Home Address (if different from child’s):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Home Phone (If different from child’s):
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Parent/Guardian Work Telephone
Please enter a valid phone number.
Parent/Guardian Mobile Phone
Please enter a valid phone number.
Emergency Contacts - your signature (*) authorizes these people to pick up your child from school:
Please Select
1
2
3
4
Name 1
Address 1
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number 1
Please enter a valid phone number.
Name 2
Address 2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number 2
Please enter a valid phone number.
Name 3
Address 3
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number 3
Please enter a valid phone number.
Name 4
Address 4
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number 4
Please enter a valid phone number.
Signature
Relationship to child
Student Medical Information:
Primary Physician:
Name
Telephone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Physician:
Name
Telephone
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Conditions: (e.g., diabetes, epilepsy, heart conditions, etc.)
Disabilities
Allergies: (e.g., hay fever, strawberries, peanuts, etc.)
Medications:
Allergies to Medications:
Submit
Should be Empty: