Medical Release Form

Name of Event Student is Attending

Parent | Legal Guardian *

Parent | Legal Guardian

First Name

Last Name

Phone Number (phone and sms capable preferred) *

Phone Number (phone and sms capable preferred)

(###)

###

####

Best Email *

Child's Name *

Child's Name

First Name

Last Name

Age *

Grade *

Home Address *

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact *

Emergency Contact

First Name

Last Name

Relation To Child *

Emergency Phone Number *

Emergency Phone Number

(###)

###

####

List Any Allergies/Physical Problems *

Date of Signature *

Date of Signature

MM

DD

YYYY

Parent Legal Guardian Signature *

Parent Legal Guardian Signature

First Name

Last Name