Medical Release Form

Medical Release Form

  • Date Format: MM slash DD slash YYYY
  • Purpose - To enable parents to authorize emergency treatment for children who become ill or injured while under school authority, when parents cannot be reached.
  • Please list any and all allergies the student may have to include medications
  • 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 emergency
    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 Dentistry
    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?
  • Guardian Signature: ______________________________________________________________ Date:________________________________________________________

    Student Signature: _______________________________________________________________ Date:______________________________________________________________
  • This field is for validation purposes and should be left unchanged.