INFORMATION AND MEDICAL RELEASE

Student name _______________________________

Address ____________________________________
____________________________________

Age _________
Date of Birth ___________
Home Phone

_______________________
Mothers name _____________________________

Work phone _______________________

Fathers name ______________________________

Work phone _______________________

Cell phone and/or pager (if available)

______________________________________________________
Emergency contact name and phone number
________________________________________________
Insurance information:
Please attach a photocopy of your childs medical insurance card. (Front &

back)
Person insured _______________________
________________________
Insurance Co. ________________________
________________________________
Group # _____________________________
________________________
Employer ___________________________

Relationship
ID#
Comments:
____________________________________

Second insurance (if applicable):

Person insured _______________________
________________________
Insurance Co. ________________________
________________________________
Group # _____________________________
________________________
Employer ___________________________

Relationship
ID#
Comments:
____________________________________

Do you wish emergency treatment for your child? Yes _____________ No

________________
Can your child be given Tylenol?
Yes _____________ No
________________
Can your child be given Advil?
Yes _____________ No ________________
Are there any medications that your child is allergic to or cannot take?
__________________________
________________________________________________________________________________________

Are there any medical conditions or other allergies that we need to be aware of?
________________
________________________________________________________________________________________
List any medications that your child takes on a regular basis (include dosage)
_____________________
___________________________________________________________________________
I give consent and permission for my child _________________________________________ to
be given emergency medical treatment if necessary at the nearest available doctor or
hospital. I also understand that the doctor or hospital bill will be my responsibility and
not the responsibility of Locust Grove Middle School. (Use the back of this form to give
any additional medical information we may need about your child.)
Parent signature _________________________________

Date ___________________________

Notary signature _________________________________ Date ___________________________