Peace Lutheran Church                                          Medical Release and Permission Form
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Name *
Birthdate *
MM
/
DD
/
YYYY
Address *
Phone: (home)
Parent Cell
Email *
Year in School *
Gender *
Mother’s Name *
Mother’s Work Phone *
Father’s Name *
Father’s Work Phone *
Emergency Contact *
(if parents cannot be reached)
Emergency Contact's Phone *
Medical Insurance Co. *
Doctor/Clinic *
Doctor/Clinic Phone *
Dentist *
Dentist's Phone *
Please check the following areas :
For your child’s safety and for our knowledge, is your child a : *
Required
Does your child have allergies? *
Does your child have or is he/she being treated for any of the following?: *
Required
Please list and explain any major illnesses your child experienced during the last year: *
Does your child wear: *
Required
Date of last tetanus shot: *
MM
/
DD
/
YYYY
Medications/Dosage (if any): *
Note: if necessary, describe in detail the nature and severity of any physical and or psychological ailment, illness, limitation, handicap, disability or condition to which your child is subject that the staff should be aware of. Submit this notification in writing and attach it to this form.
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