2025-2026 HEALTH INFORMATION & MEDICAL RELEASE

HEALTH INFORMATION

2025-2026
PARENT OR GUARDIAN #1*

First NameLast Name
ADDRESS *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL*
example@example.com
CELL PHONE NUMBER *
Please enter a valid phone number.
PARENT OR GUARDIAN #2

First NameLast Name
ADDRESS (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL
example@example.com
CELL PHONE NUMBER
Please enter a valid phone number.
NAME OF CHILD #1*

First NameLast Name
DATE OF BIRTH*

MonthDayYear
Date
HEIGHT*
WEIGHT*
ALLERGIES & SPECIAL INDICATIONS
NAME OF CHILD #2

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
HEIGHT
WEIGHT
ALLERGIES & SPECIAL INDICATIONS
NAME OF CHILD #3

First NameLast Name
DATE OF BIRTH

MonthDayYear
Date
HEIGHT
WEIGHT
ALLERGIES & SPECIAL INDICATIONS
PEDIATRICIAN/PHYSICIAN*

First NameLast Name
PEDIATRICIAN/PHYSICIAN PHONE NUMBER*
Please enter a valid phone number.
MEDICAL INSURANCE COMPANY *
INSURANCE ID*
EMERGENCY CONTACTS

Contacted for emergency, illness, pickup if the parents/guardians cannot be reached.
Contact #1 (other than parent)*

First NameLast Name
Relationship to the child(ren)*
Phone Number*
Please enter a valid phone number.
Contact #2 (other than parent)*

First NameLast Name
Relationship to the child(ren)*
Phone Number*
Please enter a valid phone number.
MEDICAL RELEASE
In the event of an emergency in which my child(ren) need(s) medical care, I give permission to the staff of the Blue Rock School to contact emergency services as needed, and I understand that I will also be called.

Please make sure your phone can receive messages.
Child #1*

First NameLast Name
Child #2

First NameLast Name
Child #3

First NameLast Name
Name of Parent or Guardian*

First NameLast Name
Signature of parent or Guardian*

Clear
Should be Empty:

HEALTH INFORMATION

EMERGENCY CONTACTS

MEDICAL RELEASE