Medical Waiver Release Form

Name

First Middle Last

Student's Date of Birth

Age

Mother/Guardian Name

First Last

Mother/Guardian Cell Phone

Father/Guardian Name

First Last

Father/Guardian Cell Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Medical Insurance Carrier

Group Number

List All Medications Taken Regularly

List Any Allergies

If allergies, does student have an Epipen?

Yes

Physician's Name

Physician's Phone Number

Are there any concerns that CCH or medical care professionals should be aware of

Alternate Emergency Contact Name (Not Parents):

Emergency Contact Phone Number

Name(Required)

Email(Required)

Phone

This field is for validation purposes and should be left unchanged.

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