Medical Release Information

Please list all/any medical problems requiring maintenance medication (i.e., Diabetic, Asthma, or Seizures)

Should a paramedic be called?

Yes No

Is your child presently being treated for an injury, sickness, or taking any form of medication for any reason?

Is your child allergic to any type of food or medication?

Does your child require any special accommodations? If yes, please describe:

The purpose of this information is to ensure that medical personnel have details of any medical problems or condition which may interfere with or alter treatment.

Contact #1:

Contact #2: