Medical Release Form Medical Release Form Student Name* First Last Student Date Of Birth* Date Format: MM slash DD slash YYYY Health Insurance Company*Purpose - To enable parents to authorize emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached.Health Insurance Number*Parent / Legal Guardian - 1st* First Last Parent/Legal Guardian Email* Enter Email Confirm Email Phone: 1st Emergency Number*Parent / Legal Guardian - 2nd* First Last Phone: 2nd Emergency Number*Allergies*Please list any and all allergies the student may have to include medicationsMedical Conditions*Please list any and all medical conditions the student may have to include medications that may alter the students participation or that medical emergency staff or res-ponders may need to be aware of in case of an emergencyEmergency Release Permission* Yes - Have My Child Treated No - Do Not Have My Child Treatd In the event an emergency should arise, every attempt will be made to contact you. Should we not be able to contact you, do we have permission to have emergency services treat your child? In doing so, you agree to hold The Newark Rotary, Free Enterprise Academy, All Organizations, All Sponsors, All Individuals, and Any Business Or Organization associating and assisting in running of the program harmless in all ways legally and financially and agree that such individuals are acting in only good faith to help your child. You further agree to not sue, hold liable, or bring any grievance against such persons or organizations in any way. This is to include DentistryClosest Emergency Location To Include Dentisty* Yes - Have my child treated by the closest and nearest hospital No - Do not have my child treated by the closest and nearest hospital In the event an emergency and permission being granted to have your child treated, the closest EMS services and hospital will be contact to help treat your child. Is this ok?If NO on the above question, please list were you would want your child transported to in case of an emergencySignatures: Please Print This Form Once CompletedGuardian Signature: ______________________________________________________________ Date:________________________________________________________ Student Signature: _______________________________________________________________ Date:______________________________________________________________CAPTCHANameThis field is for validation purposes and should be left unchanged.