Parent / Child
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Preschool Medical Release Form
Name of parent filling out form:
Does this child have any food allergies?
Type of reaction:
Is an Epi-Pen required/prescribed by a doctor?
If yes, parent is responsible for providing the Epi-pen to be stored at school.
Does this child have any asthma?
Is an inhaler required/prescribed by a doctor?
If yes, parent is responsible for providing the inhaler to be stored at school.
Does this child have any chronic or medical conditions/illnesses?
Type 1 Diabetes
Type 2 Diabetes
Other Condition, please specify:
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
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: