Student Name * First Name Last Name Date of Birth * MM DD YYYY 2023-2024 Grade * Height * Weight * Date of last tetanus shot (if known) MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/ Guardian 1 Name * First Name Last Name Parent/ Guardian 2 Name First Name Last Name Family Physician * Insurance company * Insurance Company Phone Number * (###) ### #### Policy Holder * Group/ Member ID * List any major (physical, intellectual, emotional) pre-existing or present medical conditions, disabilities, or restrictions that Student Leadership Discovery staff should know, or may prevent student from participating in any scheduled activities List any known allergies Medical Release Statement I understand that, in the event medical intervention is needed, every attempt will be made to contact immediately, the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my student as deemed necessary. I understand that my insurance coverage for my student will be used as primary coverage in the event medical intervention is needed. I understand that this Health/Medical Release Form will be completed annually, and that I will have the opportunity to update the information each time I complete a Permission Slip for a specific activity for my student. Name (parent/ Guardian if under 18) * This serves as a legally binding signature Thank you!
