2022 Medical Release Form

Medical Release Form

If you are 18 or older, please complete this form yourself.

Parents/Guardians, please provide the following information for your minor child/student.

*Please complete new form for each participant.

Participant Info

First and Last Name

Date of Birth

Address

Emergency Contact Info

Below is a list of over the counter medicaines. PLEASE CHECK beside each one that your student/child has permission to have in case of a headache, stomachache, or diarrhea.

First and Last Name(s), Phone Number(s), and Relationship to Student

Medical History

Please list any current or previous medical difficulties, operations, and/or serious illnesses for which the participant is/has been treated:

Please list all medications the participant is currently taking and any special storage instructions the medication requires:

Please list any medicines, foods, or other substances your participant is allergic to and/or any dietary restrictions the participant has:

Please list any special needs or considerations the participant may have or other relevant medical information:

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2022 Medical Release Form

Medical Release Form

Participant Info

First and Last Name(s), Phone Number(s), and Relationship to Student

Medical History

Bethlehem

Baptist

Church