Medical Release

MEDICAL RELEASE & ALLERGY INFORMATION FORM

Medical Information Form

* Indicates required field

Child's Name *

First

Last

Date of birth MM/DD/YYYY *

Allergy Information *

My child has no known allergies My child has allergies which are detailed below

Allergies and Reactions *

I understand that anaphylactic or severe reactions requiring medication must complete the 'Emergency Action Plan' on file in the office *

Yes

Other medical alerts *

Prescriptions taken on a daily basis *

Pediatrician's Name *

Address *

Phone Number *

Preferred Hospital *

Special Instructions *

Primary Insurance *

Policy/Group Number *

Health History

Hospitalized *

Yes No

Reason *

Chronic Illness *

Ear Infections/Tubes *

Speech Delay or Impairment *

Other information that would be helpful for caregivers *

Medical Release

To Whom it May Concern:
I hereby authorize the bearer, who is a staff member at Cross of Life Montessori School, to sign any forms required to admit my child for emergency treatment at the nearest facility. I do so in order to ensure that my child may recieve prompt medical attention in case of emergency when I cannot reach the facility promptly.

I certify that I will be held liable for all medical and hospital expenses incurred in this regard.

I certify that all the information on the Medical Form is true and complete.

Electronic Signature *

By checking yes, I authorize my signature typed above *

Yes No

Today's Date MM/DD/YYYY *

Submit