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MEDICAL HISTORY, AUTHORIZATION & RELEASE (ALL)

Please complete the form below. Required fields marked with an asterisk *

Child's Full Name*

Answer Required

Name of Physician*

Answer Required

Physician's Phone Number*

Number Required

Physician's Office Address

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Please list any allergies, illnesses, surgeries or other significant health information.*

Answer Required

Please list medications taken regularly by your child.*

Please indicate whether they are prescription or over-the-counter, the dosage and reason for treatment. If medication must be administerd by school staff, a "Medical Administration Form" will be required. Form will be provided when medication is delivered to school.

Answer Required

Note: In the event that your child has an accident resulting in a minor scrape, cut or bruise, only soap and water will be used as treatment. (Your child's teacher will send home an "Accident Report" to notify you of any minor accident that did not require contacting a parent or guardian during the school day.)

Medical Authorization and Release

I/We, the undersigned parent(s) or guardian(s) of the child named on the first line of this form hereby grant Second Presbyterian Weekday School authorization to seek emergency medical treatment for said child in the event that the staff is unable to contact the undersigned. Further, I/we hereby authorize any regular practicing physician chosen by the staff of Second Presbyterian Weekday School to provide medical attention to the above named child. The school will call 911/Emergency Medical Services for immediate help in life threatening or potentially life altering emergencies.

In consideration thereof, I/we do hereby release Second Presbyterian Weekday School, its staff and faculty, from and for any and all claims, demands, actions, or causes of action arising out of or anyway related to the rendering of such medical attention or the transportation of the above named child to or from such medical attention.

Preferred hospital in the event of an emergency.*

Answer Required

Electronic Signature of Parent or Legal Guardian*

Answer Required

Date:*

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