Medical Release Form Name of parent filling out form * First Name Last Name Email * Phone * (###) ### #### Child's Name First Name Last Name Does this child have any food allergies? No Yes Is an Epi-Pen required/prescribed by a doctor? No Yes Does this child have any asthma? No Yes Is an inhaler required/prescribed by a doctor? No Yes Does this child have any chronic or medical conditions/illnesses? Seizures Cardiac Condition Type 1 Diabetes Type 2 Diabetes Other Please list medications related to any health condition: Please list any other important information to help us better care for your child while at school: Initial here: This information is correct to the best of my knowledge. If parent cannot be notified and emergency care is necessary I hereby give my permission for this student to be transported to the nearest hospital and I give permission for the hospital to give emergency threaten as may be needed. I will assume responsiblity for all fees incurred by such emergency: Today's Date MM DD YYYY Thank you for choosing Kids Club House!
