Districts Medical Release Form
Please fill out this form and click submit.
District Blitz Conference, April 19-21, 2024
Name of Student
*
Signature of Parent/Guardian
*
Date
*
Email
*
This address will receive a confirmation email
Phone
*
Insurance Company
*
Policy Number
*
If Parent/Guardian are not available, please call person below:
Name
*
Relationship to Student
*
Phone
*
May we administer over-the-counter medications? (aspirin, Tylenol, Advil, antibiotic ointments, etc.)
*
Please select one option.
Yes
No
Additional comment regarding medical history, allergies, penicillin, drug reactions, use of over-the-counter medications, etc., that may be needed in treatment:
Submit
Description
Please fill out this form and click submit.
×
Please Fix the Following
