Calvary Medical Release Form
Student Information
Student Gender:
*
Male
Female
Student Name
*
First Name
Last Name
Student Date of Birth
*
-
Month
-
Day
Year
Date
Student Age
*
Student Grade Completed
*
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Student Email
example@example.com
Social Security Number
Parent/Guardian
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
*
example@example.com
Medical Information
Are you presently taking any medications?
*
Yes
No
Medication #1
Medication #1 Dosage
Medication #1 Time of Dosage
Medication #2
Medication #2 Dosage
Medication #2 Time of Dosage
Family Doctor
Family Doctor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Does this student have any chronic or acute medical problems?
Allergies to medicines:
Food allergies:
In case of an emergency, contact:
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Provider
Insurance Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Signature
*
Date of signature
*
-
Month
-
Day
Year
Date
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