Medical Release - F22/S23 Dragonfly Hybrid

Emergency Medical Info & Medical Release 2022/2023

This form is used in EMERGENCIES, please fill in all areas with valid information!
Student's Full Name *

First Middle Last
Student Birth Date *

Month Day Year
Parent E-mail *
Mother/Guardian Name: *
Home Phone Number *
Mother/Guardian Cell Phone Number *
Mother/Guardian Work Phone Number *
Father/Guardian Name *
Father/Guardian Cell Phone Number *
Father/Guardian Work Phone Number *
Street Address *
City and Zip Code *
Medical Insurance Carrier *
Responsible Party *
(who the insurance is under)
Date of birth of Responsible Party *
Group # *
List ALL medications your child takes regularly. This includes seasonal medications.
List any Allergies
If your student has allergies, do they have an Epipen? *
Students with serious medical risk, including those that have been prescribed an Epipen, must have on-site at all times, a parent or other assigned adult willing to take medical responsibility for the child.
Physician's Name *
Physician's Phone Number *
Physician's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are there any concerns that Dragonfly Hybrid or medical care professionals should be aware of in event of an emergency?
Please list any conditions or circumstances that pertain to your student that may need special attention or consideration from our staff. This includes both medical conditions, learning struggles, physical conditions that may present themselves and require additional support from us.
i.e. Dyslexia, Learning or Mobility Impairments, etc
Alternate Emergency Contact Name (Not Parents) *
Emergency Contact Phone Number *
Emergency Authorization: The undersigned hereby acknowledges that the information provided on this page is true and accurate. The undersigned understands that it is his/her responsiblility to inform the QVH Director if and when any of the information set out on this page changes. Failure to inform the Director will subject the student to termination of enrollment in Quo Vadis Homeschoolers.

I authorize the Quo Vadis staff/teachers/leaders to seek medical attention for my student and authorize medical treatment in the event that the parent(s) or emergency contact cannot be reached.
Type Full Parent/Guardian Name *
Signature of Parent/Guardian *
Should be Empty:

Emergency Medical Info & Medical Release 2022/2023