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Student Medical Release 2021/2022
If you have multiple children, you will only need to fill out one form for all children in your family.
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1
Parent Name
*
This field is required.
First Name
Last Name
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2
Parent Email
*
This field is required.
example@example.com
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3
Parent Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
Parent Phone Number
*
This field is required.
Contact #1
Area Code
Phone Number
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5
Parent Phone Number
Contact #2
Area Code
Phone Number
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6
Emergency Contact #1 Name
*
This field is required.
First Name
Last Name
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7
Emergency Contact #1 Phone Number
*
This field is required.
Area Code
Phone Number
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8
Emergency Contact #2 Name
*
This field is required.
First Name
Last Name
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9
Emergency Contact #2 Phone Number
*
This field is required.
Area Code
Phone Number
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10
Front of Health Insurance Card
*
This field is required.
Please use the lowest jpg. file size possible
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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of
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11
Back of Health Insurance Card
*
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Please use the lowest jpg. file size possible
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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of
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12
Student #1 Name
*
This field is required.
First Name
Last Name
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13
Student #1 Date of Birth
*
This field is required.
-
Date
Year
Month
Day
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14
Student #1 Phone Number
Area Code
Phone Number
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15
Student #1 - Name of Primary Care Physician
*
This field is required.
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16
Student #1 - Phone of Primary Care Physician
*
This field is required.
Area Code
Phone Number
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17
Student #1 - Please list any medication that your child will be taking. Please type instructions including the dosage and times per day it must be taken. (If none, N/A)
*
This field is required.
Huge
Large
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Small
Ok
quote
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Ok
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18
Student #1 - Drug Allergies (If none, N/A)
*
This field is required.
Huge
Large
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Small
Ok
quote
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Ok
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19
Student #1 - Date of Last Tetanus Shot
*
This field is required.
-
Date
Year
Month
Day
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20
Student #1 - Food Allergies (If none, N/A)
*
This field is required.
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Ok
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Ok
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21
Student #1 - Please list any additional info that is helpful for us to know so that we can serve your child effectively and make sure their needs are met.
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22
Do you have another child to add to this medical release?
Yes
No
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23
Student #2 Name
First Name
Last Name
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24
Student #2 Date of Birth
-
Date
Year
Month
Day
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Enter
25
Student #2 Phone
Area Code
Phone Number
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26
Is the primary care physician the same as student 1?
Yes
No
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27
Student #2 - Name of Primary Care Physician
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Submit
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Enter
28
Student #2 - Phone of Primary Care Physician
Area Code
Phone Number
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Submit
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Enter
29
Student #2 - Please list any medication that your child will be taking. Please type instructions including the dosage and times per day it must be taken. (If none, N/A)
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Ok
quote
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Ok
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30
Student #2 - Drug Allergies (If none, N/A)
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Ok
quote
Created with Sketch.
Ok
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Enter
31
Student #2 - Date of Last Tetanus Shot
-
Date
Year
Month
Day
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Next
Submit
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Enter
32
Student #2 - Food Allergies (If none, N/A)
Huge
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Ok
quote
Created with Sketch.
Ok
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33
Student #2 - Please list any additional info that is helpful for us to know so that we can serve your child effectively and make sure their needs are met.
Huge
Large
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Ok
quote
Created with Sketch.
Ok
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34
Do you have another child to add to this medical release?
Yes
No
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Submit
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Enter
35
Student #3 Name
First Name
Last Name
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36
Student #3 Date of Birth
-
Date
Year
Month
Day
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37
Student #3 Phone
Area Code
Phone Number
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38
Is the primary care physician the same as student 1?
Yes
No
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Submit
Press
Enter
39
Student #3 - Name of Primary Care Physician
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Enter
40
Student #3 - Phone of Primary Care Physician
Area Code
Phone Number
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41
Student #3 - Please list any medication that your child will be taking. Please type instructions including the dosage and times per day it must be taken. (If none, N/A)
Huge
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Small
Ok
quote
Created with Sketch.
Ok
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42
Student #3 - Drug Allergies (If none, N/A)
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Ok
quote
Created with Sketch.
Ok
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43
Student #3 - Date of Last Tetanus Shot
-
Date
Year
Month
Day
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Submit
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Enter
44
Student #3 - Food Allergies (If none, N/A)
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Ok
quote
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Ok
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45
Student #3 - Please list any additional info that is helpful for us to know so that we can serve your child effectively and make sure their needs are met.
Huge
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Ok
quote
Created with Sketch.
Ok
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46
Do you have another child to add to this medical release?
Yes
No
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Submit
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Enter
47
Student #4 Name
First Name
Last Name
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Submit
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Enter
48
Student #4 Date of Birth
-
Date
Year
Month
Day
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Submit
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Enter
49
Student #4 Phone
Area Code
Phone Number
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50
Is the primary care physician the same as student 1?
Yes
No
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Next
Submit
Press
Enter
51
Student #4 - Name of Primary Care Physician
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Submit
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Enter
52
Student #4 - Phone of Primary Care Physician
Area Code
Phone Number
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Enter
53
Student #4 - Please list any medication that your child will be taking. Please type instructions including the dosage and times per day it must be taken. (If none, N/A)
Huge
Large
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Small
Ok
quote
Created with Sketch.
Ok
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54
Student #4 Drug Allergies (If none, N/A)
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Ok
quote
Created with Sketch.
Ok
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55
Student #4 Date of Last Tetanus Shot
-
Date
Year
Month
Day
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Submit
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Enter
56
Student #4 Food Allergies (If none, N/A)
Huge
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Ok
quote
Created with Sketch.
Ok
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57
Student #4 - Please list any additional info that is helpful for us to know so that we can serve your child effectively and make sure their needs are met.
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Ok
quote
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Ok
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58
I hereby give my consent to Maranatha Baptist Church and its leaders to obtain medical or surgical care for my (our) dependent(s) should an emergency arise in which such service is indicated.
*
This field is required.
Yes
No
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59
I hereby give my consent to Maranatha Baptist Church and its leaders to take and use pictures or videos of my student(s) for promotional use.
*
This field is required.
Yes
No
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60
Digital Signature
*
This field is required.
Please type the full name of the person giving consent
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